Roll No.

: ___________
Stage One Chest No. :

IDENTIFICATION

FORM

1. Type of commission / Entry ...................................................................................................

2. Batch No. ......................................................... Stage Two Chest No. ..................................
3. Name in full ............................................................................................................................
(IN BLOCK LETTERS)
4. Fathers Name in full ..............................................................................................................
(IN BLOCK LETTERS)
D D
M M
Y Y Y Y
5.

Date of Birth (In figures)

6. Permanent Home Address ...................................................................................................

................................................................................................................................................
7. Present Address ...................................................................................................................
................................................................................................................................................
8. Tele No. ..................................................................................................................................
9. E-Mail ID ................................................................................................................................
10. Fax No. (if any) ......................................................................................................................
11. Nearest Railway Station (from permanent Home) .................................................................
Note : Any change of address should be communicated to ADG Rtg, AGs branch Army HQ
West Block III, R K Puram, New Delhi-66.
12.

Specimen Signatures (3 times):

1..........................................

2..........................................

3...........................................

13. Two visible Identification Marks..............................................................................................

................................................................................................................................................
14.

Left Hand thumb impression.

(MALE CANDIDATES)

PHOTOGRAPH

Passport Size
Photograph
(3.5 cm X 4.5 cm)

Right Hand thumb impression.

(FEMALE CANDIDATES)

CERTIFICATE OF PREVIOUS CANDIDATURES

1. I, ................................................................... (Name) a candidate for admission to the grant of
commission for ................................................... here by declare that : ---(a) I have previously reported to SSB for a similar admission as under :-- (Similar Entry)
(Type of Entry)

(SSB No/Place/Date/Year)

[ i ] ................................

....................................................................

[ ii ] ................................

....................................................................

[ iii ] ................................

....................................................................

(b) I have also previously reported to SSBs for the following commission :-- (Different Entry)
(Type of Entry)

2.

(SSB No/Place/Date/Year)

[ i ] ................................

....................................................................

[ ii ] ................................

....................................................................

[ iii ] ................................

....................................................................

[ iv ] ................................

....................................................................

[ v ] ................................

....................................................................

If at any time the above statement is found to be incorrect I undertake to refund

the Govt. of India all expenditure incurred by them on my tests and stay at the
SSB.

3. My educational qualificaton is ...............................................................................................

Date......................................

(Signature of candidate)

SERVICE SELECTION BOARD RESULT

(To be completed by the President SSB)
1. Name of the candidate...........................................................................................................
(IN BLOCK LETTERS)

2. Batch No. ............................................................. Stage Two Chest No. ..............................

3.

Marks Awarded :-(a) In figures.........................................................................................................................

(b) In words..........................................................................................................................

Station : Bhopal (MP) - 462 001

(Signature)
President

Dated : ..............................................

No............................

(FORM OF CERTIFICATE TO BE SIGNED BY THE CANDIDATE)

IMA / OTA / TGC / WSES (O) / DESSC COURSE NO.....................

I (Name, IN BLOCK LETTERS) ........................................................... a candidate

for regular / Short Services commission in the Army / Navy hereby certify that I
am attending Services Selection Board interview at my own risk and that I or my
Parent / Guardian shall not be entitled to claim any compensation or other
relief from the Govt. in respect or any injury which I may sustain in the course
of or as result or any of test given to me at the said Services Selection Board
interview whether due to my negligence or of any person or otherwise.

Station : Bhopal - 462 001

Date :

(Signature of candidate)