ONLINE APPLICATION FORMAdvt. No. CEPTAM - 07 DRDO ENTRY TEST - 2014 Closing Date - 17th Oct 2014

1. POST CODE STA'B'-[0113-MECHANICAL ENGINEERING]2. Preference For Exam City I. 05-BHUBANESWAR II. 18-KOLKATA III. 03-BENGALURU3. Candidate's Name as Recorded in X Class Certificate SANDIP KUMAR ROUL4. Father's Name PAGAL ROUL5. Mother's Name JAYANTI BEHERA6. Date of Birth (as recorded in X Class Certificate) 05 / 03 / 1992

7. a) Category

[ ] Unreserved (UR) [ ] Scheduled Caste (SC) [ ] Scheduled Tribe (ST) [ Y ] Other Backward Class

(OBC)

7. b) Sub-Category

[ ] Ex-Service Man (ESM) [ ] Govt. Servant (GS) [ ] Meritorious Sports

Person (MSP) [ ] Widow/Divorcee

[ ] Persons with Disability (PWD)

[ ] OrthopaedicallyHandicapped (OH)

[ ] Hearing Impaired (HI)

[ ] Visually Impaired (VI)

For Office Use Only :

ONLINE APPLICATION NUMBER : 90113070042

Printed On Date :4 / 11 / 2014 21:33:49

8. Nationality : INDIAN9. Willing to serve in Remote Area # : NO10. Gender :Male [ Y ] Female [ ]

11. Contact Details (Note : All particulars given below in thehead should be maintained active till the end of selectionprocess) a ) Address for Correspondence

Name : MR. SANDIP KUMAR ROUL C/O : PAGAL ROUL AT-MADHAPUR PO-KEONJHAR

City/State: KEONJHAR , ODISHA Pincode: 758001 , Landline No:

b ) Permanent Address

Name : MR. SANDIP KUMAR ROUL C/O PAGAL ROUL AT-DIMIRIA PO-DIMIRIA

City/State: KEONJHAR , ODISHA Pincode: 756121 , Landline No:

c ) Mobile No +91 - 9853664430 d ) Email sandipkumarroul@gmail.com

12. a) Educational Qualification (Mention all completed/result awaited/appearing)

Qualification Main Subjects / Trade(Specify Subject / Tradeas mentioned on theCertificate / Degree ofEQR)

University / Board Year ofPassing

Durationof Course(In years)

MaximumMarks

MarksObtained /CGPA

% of MarksSecured

X NA BSE ORISSA 2007 NA 750 505 67 XII ITI B.Sc Diploma MECHANICAL SCTE AND VT 2010 3 3750 2712 71 Grad. PostGrad. B TECH MECHANICAL BPUT ORISSA 2013 3 10 7.03 65 OTHERS2

12. b) Higher Education [for post of STA 'B' / Tech 'A'] Have you Completed or persuing M.Sc./B.Tech./B.E. degree etc.? YES [ Y ] NO [ ] Institute Name Qualification Likely Date/Date of CompletionBCET BALASORE B TECH 09/09/2014

13. Details of Exam Fee of Rs. 50/- Paid (If not exempted as per Govt. rules)

Payment Method Fee Amount Payment Date Payment ID Transaction ID Status 1161 50.00 2014-11-04 21:18:59 30232807 76984133 Processed

14. Employment Record in Govt./PSU/Autonomous Body etc. (If any)

Name of Organization Post Held Pay Scale /Grade Pay

Period From Period to Nature of DutiesPerformed

15. Important Endorsements

a) (i) Type of ID Proof : VOTER ID CARD ID No.: ASV0411496 (ii) Height (cm) : 155 Weight (kg) : 53 Identification Mark : (iii) Driving License : [for post of vehicle operator 'A' & fire engine driver only]

(ii ) Two / three Wheelers: (i ) LMV : (i ) HMV :

(b) For serving defence personnel only, claiming benefit of Ex-Serviceman

Name of Unit Rank Date ofJoining

Date ofDischarge

CO Name Contact NO.

16. Other relevant information (If any)

17. Declaration I SANDIP KUMAR ROUL son/Daughter of PAGAL ROUL 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 inmy 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 orafter the examination/selection my candidature/selection/appointment is liable to be cancelled.

18. Required at the time of document verification/truck test/interview, if shortlisted.

Place :

Date :

a) Left Hand Thumb Impression b) Signature of Candidate

Note : You are NOT REQUIRED to send print out of your application to the DRDO's office at this time. How ever, we advise to keep thisOnline application form and copy of the advertisement for claiming travel concession from Railways, and also for future references.CEPTAM does not undertake any scrutiny of application before examination and the eligibility is verified only after examination.Accordingly, mere allowing the candidates to appear in the examination will not be construed as a ground of being eligible for the postapplied.

# for details, read CEPTAM-07 advertisement

ONLINE APPLICATION NUMBER : 90113070042 , Printed On Date :4 / 11 / 2014 21:33:49