INDIAN ARMY DIRECTORATE GENERAL OF RECRUITING

Application Form for SSC(T)-43

1. Roll No. 2. Post Applied For 3. Candidate's Name 4. Father's Name 5. Mother's Name 6. Date of Birth 7. Nationality 8. Marital Status 9. Gender 10. Mobile No. 11. Email Address 12. Permanent Address
W-220 Awash Vikas coloney Amaniganj , Faizabad, Faizabad, Uttar Pradesh-224001

723942 SSC(T)-43 Purnendu Mishra Mani Kant Mishra Chandra Sheela Mishra 20/09/1992 INDIAN Unmarried Male 8130835223 purnendu220@hotmail.com

To Be attested by Gazetted Officer

13. Correspondance Address

W-220 Awash Vikas coloney Amaniganj , Faizabad, Faizabad, Uttar Pradesh-224001

14. SSB History: SNo.

Entry

Location

Year/Month

15. Educational Details: 15(a) Type of School 15(b) Education Qualification 15(c) Branch/Stream of Engineering

15(d) Date of Joining Engineering College 15(e) Date of completion of Degree 15(f) College Name 15(g) University Name 15(h) State in which University Located 15(i) Gate Score 15(j) Valid Upto 15(k) Is Diploma

Others B.Tech. Information Tech / Information Science & Engineering / Computer Engineering / Computer Science / Computer Science & Engineering / Computer Tech / Computer Science Engineering / 08/02/2010 06/30/2014 Dronacharya College Of Engineering Uttar Pradesh Technical University Uttar Pradesh --No

Subject
Physics Chemistry Maths/Biology Cumulative Percentage

Total Marks
100 100 100 67.00

Obtained Marks
71 67 63

Percentage
71.00 67.00 63.00

Semester
1 2 3 4 5 6
Declaration :-

Total Marks
1000 1000 1000 1000 1000 1000

Obtained Marks
661 664 628 642 666 662

Percentage
66.10 66.40 62.80 64.20 66.60 66.20

Cumulative Percentage
66.10 66.25 65.10 64.88 65.22 65.38

I affirm that all information supplied by me as above is true and correct, I also fully understand that if at any stage, it is discoverd that any attempt has been made by me to willfully conceal or misrepresent that facts, my candidature may be summarily rejected or employment terminated.

Signature of the candidate Place & Date : Your Registration Date & Time:2/21/2014 4:35:21 PM Your Application Submission Date & Time:2/21/2014 4:46:35 PM

Note :1. 2. 3.
The universities which have Grade Point system, need to convert Grades into %age of marks scored. Filling of cumulative %age of marks scored based on the Cumulative Grade at the end of third year/seventh semester/fourth year (as applicable) is compulsory; failing which the application will be rejected. For Candidates having only first year exams and not giving semester exams- Divide your first year marks in two equal halves and fill in 1st and 2nd semester. eg. 700/1000 is to filled as 350/500 and 350/500. Certificates attached with application form :(a) (b) (c)

Declaration :1. 2. 3. 4. 5. 6. 7.
I have read and understood the instructions and undertake to abide by them. I hereby declare that all statements made in the application are correct and true. I undertake not to have any objections in the event of my final selection on allotment of any Arms/Service in the interest of the organisation. I have never been debarred from appearing in any examination or UPSC and nor have I been arrested or convicted by a criminal court or involved in any other case registered by Police. I undertake not to make any claim or compensation if at any stage of selection, my ineligibility is detected and my candidature is cancelled as a result thereof. This is the only application submitted for (SSCT-43) course and any duplicate application if detected at any stage, my candidature be cancelled. Any misinterpretation and wrong declaration/ concealment of information in the application will render my candidature to be cancelled and I may be debarred from this course. I have never been withdrawn from NDA, IMA or OTA or any service training academy on disciplinary grounds.

8. 9. I am employed with ________________________ & I have informed my employer in writing that I am applying for commission in the Army. 10. In the eventuality of being recommended by SSB I will have no objection to be medically examined by board of Male/Female doctors, provided a
lady medical officer is present (applicable only to lady cadets)

11. I undertake to be debarred & my candidature be cancelled, if at any stage of selection I indulge in any violation of local orders concerning

discipline aspects. 12. I undertake not to marry till I complete the full training at the training academy, in case inducted. I also understand that in case of my final selection, my appointment will be provisional subject to satisfactory police and educational verification. 13. In case of resignation from Academy, cost of training will be paid by me.

14. This application is accepted provisionally subject to meeting eligibility criteria.

Note :1.
After applying online, candidates are requested to take a print out, paste his / her attested photograph in the space provided, sign it in blue ink in the space provided and carry the application and acknowledgement without fail along with the original certificates along with the certificate from the college principal regarding conversion of cumulative grade into %age of marks and with a valid proof of identity to the Selection Centre when called for the interview. If candidate does not carry the above said documents to the Selection Centre for interview, his candidature will be cancelled. It may be noted that depending upon the total number of applications received by this office, Recruiting Directorate reserves the right to shortlist and to fix cut off percentage of marks for SSB interview. No representation will be entertained in this aspect. NO DEVIATION FROM THE NOTIFIED QUALIFICATIONS/STREAM IS ACCEPTABLE. CLAIMS OF COURSE CONTENT/SIMILAR STREAM WILL NOT BE ACCEPTED. Any wrong details filled in above application will lead to cancellation of the candidature and suitable action will be taken against the candidate. Applying second time on line or by post for SSC(T)-43 will lead to cancellation of candidature.

2. 3. 4. 5.

CERTIFICATE BY PRINCIPAL/HEAD OF THE TECHNICAL INSTITUTIONS TO BE SUBMITTED BY FINAL YEAR/SEMESTER CANDIDATES

Certified that Shri ________________S/o ________________ Date of Birth________________is studying in final year/final semester of B.E/B.Tech ______________________ (Branch of Engineering) in this University/College/Institute and his final year/semester examinations will be over by 01 Oct 2014. Place :________________ Date :________________ Signature______________________ Designation____________________

Seal

Note: Certificate signed by Heads of Departments will not be acceptable.