xk siuh;CONFIDENTIAL

O;fDrxr tkudkjh iz’ukoyhPERSONAL INFORMATION QUESTIONNAIRE

Mhñ vkbZñ ihñ vkjñ iz’ukoyh la[;k 107 - A ¼la’kksf/kr½DIPR Questionnaire No. 107- A (Revised)

vksñ vkbZñ vkjñ @O.I.R. .

1 - p;u cksM Z ¼la[;k vkSj L;ku½Selection Board (No. & Place)

cSp lañBatch No.

pSLV lañChest No.

;wñ ihsñ ,lñ lhñ ;k vU; jksy uEcjUPSC / Other Roll No.

2 - lqLiI sV v{kjks esa uke ¼tSlk eSfVªd izek.k&i= esa gS½Name in CAPITALS (As in the matriculation certificate) __________________________________________________________________

3 - firk dk uke @ Father’s Name __________________________________________________________________

4 - (a) vf/kdk a’k le; vkokl dk LFkku ¼LFkku] ftyk] jkT;½ ¼LFkku dh vuqekfur tula[;k lfgr½Place of Maximum Residence (Place, District, State)(with approximate population of the place) __________________________________________________________________

(b) orZeku vkokl dk LFkku ¼LFkku] ftyk] jkT;½ ¼LFkku dh vuqekfur tula[;k lfgr½Place of Present Residence (Place, District, State)(with approximate population of the place) __________________________________________________________________

(c) LFkkb Z vkokl dk LFkku ¼LFkku] ftyk] jkT;½ ¼LFkku dh vuqekfur tula[;k lfgr½Place of Permanent Residence (Place, District, State)(with approximate population of the place) __________________________________________________________________

¼og ftyk eq[;ky; gS vFok ugh½@ (Whether District HQ or not) __________________________________________________________________

5 - fuEu fooj.k Hkjsa @ Fill in the details below :-

6 - (a) D;k ekrk&firk ftfor gS a ? @ Parents Alive gka@ugha @ Yes / No(b) ;fn ftfor ugha rks ekrk@ firk dh e`R;q ds le; vkidh vk;q

If not alive, your age at the time of Mother’ s / Father’s death __________________________________________________________________

(c) ekrk&firk@laj{kd vkSj Hkkb Z&cgu ds O;olk;@vk; ¼tks ykxw gks½ @ Parents’ /Guardian’s and Siblings’ Occupatio n/ income (as applicable) :-

7 - ’kSf{kd fjdkMZ ¼eSfVªdq ys’ku@lEd{k ifj{kk ls vkjEHk djds½ @ Educational Record (commencing from Matriculatio n / Equivalent Examination) :-

jkT; vkSj ftykState & District

foo k fgr@vfoo k fgr@ fo/ k qjMarried@Single@Widower

/ ke ZReligion

vuqlwfpr tkfr@ tutkfr ;fn gSWhether SC @ ST@ OBC

ekr ` Hkki skMother Tongue

tUe frfFkDate of Birth

fooj. k @ Particulars f’ k{kk@Education O;olk;@Occupation ekfld vk;@ Income per month

xk siuh;CONFIDENTIAL

firk@Father

ekrk@Mother

laj{kd@Guardian

cM+k Hkkb Z@cgu@ Elder Brother@ Sister

cM+k Hkkb Z@cgu@ Elder Brother@ Sister

NksVk Hkkb Z@cgu@ Younger Brother@ Sister

NksVk Hkkb Z@cgu@ Younger Brother@ Sister

i zk Ir ;k sx;rk, s aQualificationacquired

laLFkku dk iwjk ukeFull Name ofInstitution

ck sM Z@ ; qfuo fl ZV hBoard@University

oi s ZYear

Js.kh o vadi z fr’ kr@Div.& Marks %

f’ k{kk dk ek/;eMedium ofInstruction

Nk=koklh@fnu Nk=Boarder@ DayScholar

vlk/kkj.k mIyfC/ k] ; fndksb Z gks@ Outstandingachievement, if any

eSfV ªd@ gk;j l Sd saMjhMatric@ Hr. Sec.

10+2 ds le{k10+2 Equivalent

Lukrd@Graduation

Lu krdk sRrj@ O;olkf;dPost-Graduation@Professional

xk siuh;CONFIDENTIAL

8 - vk;q ¼oisZ vkSj ekg½ / Age ( Years & Months) mpkabZ ¼ehVj esa½ / Height (in Metre) otu ¼fdyksxzke esa½ / Weight (in Kilogram)

______________________________________ _____________________________ __________________________________

9 - orZeku O;olk; vkSj O;fDrxr ekfld vk;] ;fn gSPresent Occupation and personal monthly income, if any ______________________________________________________________________________

1 0 - (a) jkI sVªh; dSfMV dksj izf’k{k.k @ N.C.C. Training gka@ugha @ Yes / No(b) ;fn gkWa ] rks dq y izf’k{k.k ¼fooj.k uhps nks½ @ If Yes, Total Training (Give details below)

1 1 - (a) [ksydwnksa esa Hkkxhnkjh @ Participation in games & sports :-

(b) ’kksd@#fp;ka @ Hobbies / Interest ______________________________________________________________________________(c) ikB~; fois;srj lkewfgd dk;Zdykiksa esa Hkkxhnkjh@ Participation in extra-curricular, activities :-

(d) jkI sVªh; dSMsV dksj@ LdkmfVax@ [ksydw n@ ikB~;sRrj vkSj vU; {ks=ksa esa mRrjnkf;Ro dk in Position of responsiblity/offices held in NCC/Scouting ______________________________________________________________________________

Sports Team/Extra-curricular group and other fields ______________________________________________________________________________

1 2 - (a) deh’ku dk Lo#i @ Nature of Commission(b) lsok dk p;u @ Choice of Service

1 3 - rhu lsokvksa esa deh’ku ds fy, fdrus ekSds ys pqds gSa &Number of chances availed for commission in all three Services ______________________________________________________________________________

1 4 - fiNys lHkh lk{kkRdkjksa dk fooj.k] ;fn dksb Z gks ¼vkehZ @ usoh @ ,;j QkslZ p;u cksM Z½Details of all previous interviews, if any (Army @ Navy@ Air Force Selection Boards)

dq y izf’k{k.k@ Total Training

dz e lañ@Sl. No.

ios’k dk izdkj ftlds fy, cSBsType of Entry

[ksy @ dz hM+k dk ukeGames@Sports

dk;Zdyki lewg dk ukeName of the activity group

Lda/k@ Wing i zH k kx@ Division izkIr izek.k i=@Certificate Obtained

Hkkx ysus dh vof/k@ Period or durationof Participation

Ld wy@dky st@fo’ofo}ky;@vU; tgk Wadk izfrfuf/kRo fd;k @ RepresentedSchool / College / University / Other

vlk/kkj.k fuI sifr] ;fn dksb Z gksOutstanding achievement, if any

Hkkx ysus dh vof/k@Duration of Participation vlk/kkj.k fuI sifr] ;fn dksb Z gksOutstanding achievement, if any

xk siuh;CONFIDENTIAL

,lñ ,l ñ chñ uañ vkSj LFkkuSSB No. & Place

rkj h[ k@Date pSLV vkSj cSp uañChest No.@ Batch No.