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UNION PUBLIC SERVICE COMMISSION

DETAILED APPLICATION FORM [DAF]-I
CIVIL SERVICES (MAIN) EXAMINATION, 2020

RID. : 12016180347
Roll No. : 0705599
Name : SIDDHARTHA SHNKAR KHAMARI
Email : siddharthkhamari@[Link]
Mobile : 9337895985

1. (a) Date of Birth | 01-07-94

(b) Age Relaxation claimed | NO

2. (a) Address for correspondence to which | BRAHMAPURA

Communication is to be sent | PATNAGARH
Post Office: | PATNAGARH
City: | BALANGIR
District: | BALANGIR
State : | ODISHA
Pin Code : | 767025
(b) Telephone No. (with STD Code) | 93378-95985
(c) Mobile No. | 9337895985
(d) Fax No. |
(e) E-mail address | SIDDHARTHKHAMARI@[Link]
(f) Permanent Postal Address | BRAHMAPURA
| PATNAGARH
Post Office: | PATNAGARH
City: | BALANGIR
District: | BALANGIR
State : | ODISHA
Pin Code : | 767025

3. Gender : | MALE

4. Marital Status : | UNMARRIED

(If Married, Nationality of spouse) |
5. (a) Citizenship : | A CITIZEN OF INDIA.(1)
(b) Nationality : | INDIAN

6. Mother tongue : | ORIYA

7. Place of Birth :
If born in India: | YES
Post Office | PATNAGARH
City/Town/Village | PATNAGARH

Roll No. :- 0705599 |

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District | BALANGIR
State | ODISHA
Pincode | 767025

8. (a) Community | UNRESERVED (4)

Note 1: Candidate belonging to OBC but coming in the 'Creamy Layer' and thus not being entitled to OBC
reservation should indicate their community as 'Unreserved (others) Code No. 4'.
Note 2: Candidates belonging to neither SC,ST,OBC communities nor EWS should opt 'Unreserved (others)
Code No. 4' against the column of community and not leave it blank.
Note 3: No change in the community status already indicated by candidate in his / her application form for
this examination will be allowed by the Commission except in the circumstances mentioned in the
Rule 23 of CSE Rules, 2020.
Note 4: In case you are a 'SC, ST, OBC(Non Creamy Layer) or EWS' candidate, upload a scanned copy of
certificate in support of your claim. For, SC/ST/OBC(Non Creamy Layer)/EWS candidates, it should be
issued prior to the date of closure of online application form for Civil Services (Preliminary)
Examination,2020 (i.e. prior to 03.03.2020).
Note 5: 'Income and Asset Certificate' of Financial Year 2018-19 (i.e. for the period from 1st April, 2018
to 31st March, 2019) must only be submitted as per the prescribed format by the candidates
seeking reservation under EWS Category. Certificate of any other Financial Year shall not be
treated as valid.
(b) Certificate No. |
(c) Date of issue |
(d) Designation of issuing authority |
(e) Full address of issuing authority |

(f) Name of the Caste as mentioned in | ()

the Community Certificate and |
Name of the issuing State
[For SC/ST/OBC Candidates] / Financial Year of Income for EWS Candidates.
(g) If you belong to any of the minority
Communities notified by the Government
(Muslim/Christians/Sikhs/Budhists/
Zoroastrians[Parsi]/Jains) |
(h) If yes, Name of the Minority
community |

9.1.(a) Whether you are a candidate with | NO

Benchmark Disability (upload a
scanned Certificate of disability)
If yes, disability certificate form |
(b) Category |

(c) Percentage of disability as indicated in |

the Certificate of Disability
(d) Certificate No. |
(e) Date of Issue |
(f) Designation of issuing authority |
(g) Full address of issuing authority |
(h) Would you require scribe in the |
Examination
Note 1: The Persons with Benchmark Disabilities in the categories of blindness, locomotor disability (both arm

Roll No. :- 0705599 |

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affected – BA) and cerebral palsy will be provided the facility of scribe, if desired by the person. In case
of other category of Persons with Benchmark Disabilities as defined under section 2(r) of the RPWD
Act, 2016, the facility of scribe will be allowed to such candidates on production of a certificate to the
effect that the person concerned has physical limitation to write, and scribe is essential to write examination
on his/her behalf, from the Chief Medical Officer/ Civil Surgeon/Medical Superintendent of a Government
Health Care institution as per proforma at Appendix – IV of the Notice of CSE, 2020 dated 12th
February, 2020.
Note 2: The candidates have discretion of opting for his/her own scribe or request the Commission for the same.
Note 3: The qualification of the Commission’s scribe as well as own scribe will not be more than the minimum
qualification criteria of the examination. However, the qualification of the scribe should always be
matriculate or above.
Note 4: The Persons with Benchmark Disabilities in the category of blindness, locomotor disability (both arm
affected – BA) and cerebral palsy will be allowed Compensatory Time of twenty minutes per hour
of the examination. In case of other categories of Persons with Benchmark Disabilities, this facility will
be provided on production of a certificate to the effect that the person concerned has physical limitation
to write from the Chief Medical Officer/ Civil Surgeon/ Medical Superintendent of a Government
Health Care institution as per proforma at Appendix – IV of the Notice of CSE, 2020 dated 12th
February, 2020.
(h)(a) If yes, "Commission's Scribe" or "Own |
Scribe"
(i) Would you require any assistive |
device(s)
(j) Would you require question paper in |
larger font size?

Note: Larger font is only for PwBD Candidates suffering from Blindness/ Low Vision.
9. 2. (a) Have you ever been recommended as a | NO
PwBD candidate in the examinations
conducted by the UPSC in the past?

(b). If yes, mention name and year of the examination(s) with Roll No.
Name of the Examination Year of the Roll No.
Examination

(c) Whether such recommendation was on | NO

the basis of the Certificate of Disability
NOW UPLOADED by you for the
CS(M) Exam, 2020?
(d) After any such recommendation by the | NO
UPSC were you ever found UNFIT/
NOT RECOMMENDED by the Central
Standing Medical Board or any other
Medical Board constituted by the
Government with regard to your
physical disability?
(e) If yes, provide details thereof |

10. Choice of Centre for Examination | CUTTACK

11. (a) Do you hail from Arunachal Pradesh/

Manipur/Meghalaya/Mizoram/Nagaland/
Sikkim and are claiming exemption

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from appearing in INDIAN LANGUAGE
FOR PAPER A? | NO
(ii)Indian Language for Paper A | ORIYA
(b) Optional Subject for paper VI & VII | ANTHROPOLOGY

12. (a)Language Medium for Examination

for Paper I to Paper V
(Essay and General Studies) | ENGLISH

(b) Language Medium for Examination

for Paper VI to Paper VII (Optional
Subject as at (b) of Col. 11 above) | ENGLISH

(c) In case of Sindhi and Santhali

type of script should be indicated
by the candidate |

(d)Language Medium for Interview

Test(i.e. para 27 of the Instructions)
to the Candidates) | ENGLISH

13. (a) Name of Father | LATE. SATYA NARAYAN KHAMARI

(b) Name of Mother | SUMITRA KHAMARI
(c) Nationality of Father | INDIAN
(d) Nationality of Mother | INDIAN
(e) Father's Profession: | DECEASED
(f) Mother's Profession: | HOUSEWIFE
(g) If your father is in service, the post held by him
(g)(i) if retired, indicate the post held
by him at the time of his retirement | PEON IN BLOCK EDUCATION OFFICE IN ODISHA
(h) If your Mother is in service,the post held by her
(h)(i) if retired, indicate the post held
by her at the time of her retirement | HOUSWIFE
(i) Annual income of your Father | RS.0
(j) Annual income of your Mother | RS.200000
(k) State to which your Father originally | ODISHA
belongs
(l) District to which your Father originally | BALANGIR
belongs
(m) State to which your Mother originally | ODISHA
belongs
(n) District to which your Mother originally| BALANGIR
belongs
(o) Father's present postal Address | BRAHMAPURA
(If deceased give last address) | PATNAGARH
Post Office: | PATNAGARH
City: | BALANGIR
District: | BALANGIR
State : | ODISHA
Pin Code : | 767025
(p) Mother's present postal Address | BRAHMAPURA

Roll No. :- 0705599 |

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(If deceased give last address) | PATNAGARH
Post Office: | PATNAGARH
City: | BALANGIR
District: | BALANGIR
State : | ODISHA
Pin Code : | 767025

(q) Whether your family owns or possesses

any of the following assets.
i. 5 acres of agricultural land and above;
ii. Residential flat of 1000 sq ft. and above;
iii. Residential plot of 100 sq. yards and
above in notified municipalities;
iv. Residential, plot of 200 sq. yards and
above in areas other than the notified
municipalities. | YES

14.1(a) Do you possess the prescribed Educational

Qualification (Vide rule-7 of the rules of the Examination)?
Please upload a scanned copy of the Certificate
if the answer is "YES" | YES
(b) Certificate No. | BDC150103534
(c) Date of issue | 05-02-2016
(d) Designation of issuing authority | VICE CHANCELOR
(e) Full address of issuing authority | ROURKELA

Note : If you do not possess the prescribed educational qualification as mentioned in rule-7 of the
examination your candidature is liable to be cancelled. The proof of passing the requisite examination
should be dated earlier than the due date (closing date) of Detailed Application Form-I of the Civil
Services (Main) Examination.

(f)(i) Do you have any basic Educational

Qualification or higher qualification
obtained from a foreign institution? | NO

14.2 Educational Qualifications : Commencing with Matriculation or equivalent examination till Graduation:-
(Please upload scanned copy of all Certificates/Degree)
Examination Class/ Percentage CGPA Year of Subject(s) Name of Name of
Passed Division of Score Out of School/College Board/University
/Grade Marks(%) Passing /Institution
10th or Equivalent 1ST 83 2009 SCIENCE RAMAI HIGH BSE ODISHA
SCHOOL
PATNAGARH
12th or Equivalent 1ST 73 2011 SCIENCE TRIVENI ACADEMY CHSE ODISHA
Stream at Graduation Level :-- ENGINEERING
B. TECH. 1ST 7.15 10 2015 MECHANICAL IGIT SARANG BPUT ROURKELA

15.(i) Have you ever been employed? : | YES

Roll No. :- 0705599 |

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If yes, Are you in
Government/Public Enterprise | YES

If yes, Date of intimation in writing

to your Head of Office/Department
regardingappearing in Civil Services
Examination 2020 | 29-10-2020

Note: The candidates employed in Government/Public Sector Enterprise/Government Autonomous Bodies

must ensure that they have intimated their parent Department before applying for this Examination with
proof of receipt by the Department. If it found, that the candidates have not done the same, their
candidature is liable to be rejected forthwith without any further notice.

Details of your employments (in chronological order till date)

Designation/Posi Monthly Whether Perman Period Name of Place of Employment
tion remuneration ent/Temporary/ From To employer/ (Address)
(Total) in Rs. Ad hoc etc. Organisation/
Firm/Individual
ASO 45000 TEMPORARY 26-07-2019 29-10-2020 GOVT OF ODISHA BHUBANEWAR

15.(ii) Have you been self-employed?: | NO

16. Have you ever been debarred by

the UPSC from any of its
Examinations/Selections? | NO

17. Whether you have ever applied for

U.P.S.C. Examination /Recruitment:- | YES
Details of other application for Examination/Recruitment held/to be held by UPSC :-
Name of Examination/Post Month and Roll. No. Whether you Whether you Whether you Whether continuing till
year of appeared at appeared at were recomm date or resigned(with date)
Examination the the Interview ended for
/Advt./Item Examination appointment
No. for
Recruitment
CIVIL SERVICES (PRE) OCTOBER 0705599 YES NO NO NA
2020

18(a). How many times have you appeared

at the Civil Services(Pre) Examination
so far, including the current
Examination held in October, 2020 | 1

18(b). Details of Examination in which you have appeared including CS(P), 2020
Year 2020
Roll No. 0705599

19. Have you ever accepted allocation

Roll No. :- 0705599 |

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to a Service/Post on the basis
of Civil Services Examination
held in earlier years? | NO
(a). Year of the Civil Services
Examination on the basis of which
you had been last allocated to
service/post |
(b). Name of service/post to which
allocated |
(c). Your Roll No. for the examination |
(d). Whether you were appointed/joined
Service? |

(e). Whether you are continuing in that

Service/Post? |

(f). If you have resigned from such post/service

Mention date of acceptance of the resignation
by the Competent authority |

20. Fee Payment Details (Subject to Verification) :-

Application No. | 12090705599
Transaction-Id | 202030796776943
Paid (in Rs.) | 200
Agency Name | State Bank of India
Mode of Payment | By Debit Card/Credit Card

Details of Fee paid:Candidates applying (excepting Female/SC/ST/PwBD candidates who are exempted from payment
of fee) for Civil Services (Main) Examination are required to pay a fee of Rs.200/- (Rupees Two
Hundred only) either by depositing the money in any Branch of SBI by cash, or by using Net Banking
facility of SBI or by using Visa/Master/Rupay Credit/Debit card.

21. Photo-ID Proof | AADHAR CARD (XXXXXXXX2924)

22. List of Scanned documents uploaded by the candidate:-

--> Scanned Copy of proof of date of birth as prescribed in Para below Note IV under Rule 6 of the rules
for the exam. [Col. 1(a) of this form]
--> Scanned Copy of the certificate of graduation or equivalence educational qualifications (including a
copy of recognition letter / equivalence certificate from AIC/UGC, if applicable)[Col. 14 of this form]
--> Copy of the selected Photo ID Proof (viz. Aadhaar Card, Voter Card, PAN Card, Passport, Driving
Licence or any other Photo ID Proof issued by the Central/State Government.)
--> Undertaking “A” for Government employees in the prescribed format annexed with Instructions to
Candidates. [Ref. Col. 15(i) of this form and Para 13 of the Instructions to the candidate]

Roll No. :- 0705599 |

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DECLARATION BY THE CANDIDATE

I, hereby declare that all statements and entries made in all the columns of this application are true,
complete and correct to the best of my knowledge and belief.

2. That I have read Rule 14 of the Rules of the Civil Services Examination, 2020 published in Part I –
Section 1 of the Gazette of India Extraordinary dated 12th February, 2020 and understand that in the
event of any information being found false or incorrect or ineligibility being detected before or
after the examination, or flouting of any instructions given by the Commission alongwith e-Admit
card/ Question – cum – Answer Booklets/ e-Summon letter [Link] can be taken against me by
the Commission.

3. That I further declare that I fulfil all the eligibility conditions regarding age limits, educational
qualifications etc. prescribed for admission to the Examination. I have not exhausted the number of
attempts admissible to me under the Rule 4 of the Rules of the Examination, 2020.

4. That I have not withheld any information required as per this Detailed Application Form- I.

5. I have thoroughly scrutinised the list of scanned documents as enumerated in Column 21 and 22
of the DAF-I and uploaded scanned copies of all the documents relevant for me.

6. That I have read the Rules of Examination and the instructions carefully and I hereby undertake to abide
by them.

7. That I have informed my Head of the Office/Department in writing that I have applied for this
examination as required in Col. 15 (i) of the DAF-I.

Signature of the Candidate

[Note: Online submission of the DAF-I by the candidate within prescribed time period is
construed as his/her signed applicaion]

Roll No. :- 0705599 |

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