APPLICATION FORM DRDO ENTRY TEST – 2011 SECTION ‘C’

Closing Date: 18th Feb, 2011

1. Post Code (See SEC ‘A’) 2. Preference for Exam City (Write Code) I. II. III.

3. Candidate’s Name as recorded in X Class Certificate: (Leave one blank space between parts of the name)

4. Father’s / Mother’s / Husband’s Name (Leave one blank space between parts of the name)

5. A) Date of Birth (as recorded in X Class Certificate) D D M M Y Y Y Y Age as on

Closing Date

YY MM

B) (i) Are you seeking age relaxation? YES NO

(ii) If yes, Attach proof on standard format

6. Category (Please tick () in the appropriate Box(es))

Category Sub-category Unreserved (UR) Scheduled Caste (SC) Scheduled Tribe (ST) Other Backward Class (OBC)

Ex-Service Man (ESM) Govt. Servant (GS)

Meritorious Sports Person (MSP)

Widow/Divorcee

PWD :

Orthopaedically Handicapped (OH) Hearing Impaired (HI) Visually Impaired (VI)

Other (specify)..…….........................................

7. NATIONALITY

8. GENDER Male Female

9. A) Address for Correspondence

(This address shall be used till the end of selection process)(Capital Letters)

NAME: ______________________________ C/o: ________________________________ ADDRESS: ____________________________ ______________________________________________________________________

STATE:

PIN:

B) Present Address (Capital Letters)

NAME: ______________________________ C/o: ________________________________ ADDRESS: ____________________________ ______________________________________________________________________

STATE:

PIN:

C) Telephone Nos. Landline

Mobile

D) E-mail

_________________________@_____________________

10. Educational Qualifications (Attach Self Attested Copy as Proof)

Examination Passed/ Appearing Main Subjects/ Trade University/ Board Year of

Passing Duration

of Course % of Marks

Secured Division

X

XII

B.Sc./Diploma/ITI

Master’s Degree

Others/ Pursuing

11. Fee Details A. Fees Paid Fees Exempted (Attach appropriate proof, if exemption claimed)

B. Details of IPO Name of Post Office Serial No(s). of IPO Date of Issue Amount (`)

Affix Recent Passport size

coloured Photograph, Self attested

For Office Use Only:

Left hand Thumb

Impression

Signature of the Candidate

12. Mention details if registered in Employment Exchange (Optional)

13. Employment Record in Govt./PSU/Autonomous Body etc.

Name of Organization Post Held Pay Scale/Grade Pay Period Nature of Duties performed From To

14. ENDORSEMENT FOR THE SERVING DEFENCE PERSONNEL CLAIMING BENEFITS OF EX-SERVICEMAN

Ref/Letter No. ………………………………….. Date ……………………………………..

The application of (Rank) ………………………………… (Name) ……………………………………………………………………………

(Date of Birth) …………………………… (Date of Joining) ………………………. (Date of Discharge*) ………………………… is hereby forwarded with the affirmation that we have no objection to his/her application being considered.

* Only personnel whose date of discharge is within one year from the closing date (Thus, last date is 17th Feb, 2012) will be considered.

Signature Competent Authority

(with office seal)

15. Any other relevant information …………...………………………………………………………………………………………………….………

16. Declaration: I ………………………………………………..….…… Son/Daughter/Wife of …………………………………………………………. hereby declare that :

A) All the statements made in this application are true, complete, and correct to the best of my knowledge and belief, and have been filled in my own handwriting.

B) I have submitted only one application for one Post in response to this advertisement. C) I have read and understood all the provisions mentioned in the advertisement and undertake to abide by them. 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/appointment is liable to be cancelled.

17. (A) Left hand Thumb Impression (B) Signature of Candidate PLACE : ……………………………………………. DATE : …………………………………………….

Name & Address of Employment Exchange Registration No. Date of Registration

18. Please tick mark () the following CHECK LIST-

(i) Application Form signed on both pages and photograph pasted (ii) Self Attested Copies of all required Certificates/Documents attached (iii) Proof of Age (i.e. self attested copy of X-Class Certificate) attached (iv) IPO for examination fee attached (v) Self Attested Copies of SC/ST/OBC/PWD etc certificate attached, if claimed

Note: Candidates are advised to retain the photocopy of their application form and copy of the Advertisement for claiming concession from Railways.