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CENTRE FOR PERSONNEL TALENT MANAGEMENT (CEPTAM) DEFENCE RESEARCH & DEVELOPMENT ORGANISATION (DRDO) MINISTRY OF DEFENCE, GOVT OF INDIA
Application Form [CEPTAM - 06] DRDO ENTRY TEST - 2013

Application No.

00118279911

SMS Registration No. Post

010118004115 0118-STA 'B' (Mechanical) Preference 1 : 01 - Agra

Preference for Exam City

Preference 2 : 04 - Bhopal Preference 3 : 16 - Kanpur

A. Personal Details

Candidate's Name as recorded in X Class Certificate (Leave one blank space between parts of the name) Father's/ Mother's/ Husband's Name Leave one blank space between parts of the name (Do not use Mr/Mrs/Sh/Smt etc) Gender Date of Birth Category Are You an Ex-Service Man (ESM) Are You a Govt. Servant (GS) Are You a Meritorious Sports Person(MSP) Are You a Widow / Divorce Are You Physically Disabled Nationality

HEMANT KUSHWAHA

HARIOM KUSHWAHA

male 06/02/1991 Other Backward Class(OBC) No No No No No Indian

B. Communication Details [All particulars given below should be maintained active till the end of selection process]

Address1 *

125 MUKARYANA INSIDE DATIA GATE

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Address2 Address3 Address for Correspondence City * State * Pincode * Country * Address1 * Address2 Address3 Permanent Address City * State * Pincode * Country * Email ID: STD Code Phone Number Mobile No. JHANSI UTTAR PRADESH 248002 India JHANSI UTTAR PRADESH 248002 India 125 MUKARYANA INSIDE DATIA GATE JHANSI JHANSI

ajay.verma647@gmail.com +91 9795850144

C. Educational Qualifications

Main Subjects/Trade Exam (Specify subject/trade as mentioned on the certificate/degree of EQR) X XII Diploma Pursuing Others's SCIENCE GROUP PCM MECHANICAL APPRENTICE UP BOARD UP BOARD BTEUP LUCKNOW NAC 06-2006 06-2008 07-2012 05-2014 1 1 3 1 University/Board Year of Passing Duration of Course(in Years)

Marks Obtained & Maximum Marks(eg. 238/500) 360/600 281/500 1567/2200

% of Marks Secured 60.00 56.20 71.23

Specify Subject/Trade as mentioned on certificate/diploma/degree of EQR MECHANICAL Exempted (SC/ST/ESM/PWD/WOMEN Etc) Payment Mode If Offline, details of IPO Name of the Post Office Serial No(s). of IPO Date of Issue Amount CITY POST OFFICE JHANSI 71G 200410 18/05/2013 50 No OFFLINE

Employment Record in Govt./PSU/Autonomous Body etc (if any) ?

? (Forward application through proper channel with advance copy before closing date) *

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No

D. Important Endorsements

(a) (i) Mention Photo Identify Proof details (PAN Card/ Voter Id/Passport/College Id/ Aadhaar/ Govt Id card) (Attach Copy). The Same is to be produced during the entire process of recruitment (Driving License is not a valid Id Proof). Type of Proof No. (ii) For the Post of STA 'B' & Technician 'A' Only (fill up as applicable) Are you pursuing M.Sc./B.E./B.Tech Degree/ Ph.D: No VOTER CARD ZTU2337376

Office Seal & Date

Signature Of Competent Authority

Any other relevant information /Specific requirements by VI candidates, if any I hereby declare that :

a. I have read and understood all the provisions mentioned in the advertisement and undertake to abide by them. b. All the statements made in this application are true, complete, and correct to the best of my knowledge and belief, and have filled it in my own handwriting. c. I have submitted only one application for one Post in response to this advertisement. d. I understand that in the event of any information being found suppressed, false or incorrect or any ineligibility being detected before or after the examination/selection, my candidature/selection/ appoinment is liable to be cancelled. Please tick mark ( ) the following CHECK LIST:

a. Application form duly signed on both pages and coloured photograph(with Name and date of photo) pasted. b. Proof of Age(i.e. self attested copy of X-Class Certificate) attached c. Self Attested Copies of EQR Certificates attached d. Self Attested Copies of Driving License attached (For Civillian Driver 'A' and Fire Engine Driver 'A' only) e. Copy of ID Proof(as per details filled in application form) attached (NO ENTRY IN EXAMINATION CENTRE WITHOUT ID PROOF). f. IPO for examination fee, if applicable attached. g. Self Attested Copies of SC/ST/OBC/PWD/ESM etc if claimed, certificates attached. h. Self addressed stamped post card (indicating post code, post name & subject) for acknowledgment at the end of all enclosures attached

Left Hand Thumb Impression of Candidate

Signature of Candidate

Copyright 2013, CEPTAM, DRDO. All rights reserved.