ONLINE APPLICATION FORM

Advt. No. CEPTAM - 07 DRDO ENTRY TEST - 2014 Closing Date - 17th Oct 2014
For Office Use Only :

ONLINE APPLICATION NUMBER : 90104001950

Printed On Date :3 / 10 / 2014 10:48:11

8. Nationality : INDIAN
9. Willing to serve in Remote Area : NO
10. Gender :Male [ Y ] Female [ ]

11. Contact Details (Note : All particulars given below in the

head should be maintained active till the end of selection
1. POST CODE process)
STA'B'-[0104-CIVIL ENGINEERING] a ) Address for Correspondence
2. Preference For Exam City
I. 18-KOLKATA Name : MR. SAMIR BARAN BERA
II. 05-BHUBANESWAR C/O : RANAJIT BERA
III. 20-PATNA VILL- BAJABERIA, PO- SRIKRISHNAPURE
3. Candidate's Name as Recorded in X Class Certificate DIST- PURBAMEDINIPUR
SAMIR BARAN BERA
4. Father's Name City/State: PURBAMEDINIPUR , WEST BENGAL
RANAJIT BERA Pincode: 721659 , Landline No:
5. Mother's Name
SHYAMALI BERA b ) Permanent Address
6. Date of Birth (as recorded in X Class Certificate)
20 / 07 / 1990 Name : MR. SAMIR BARAN BERA
7. a) Category C/O RANAJIT BERA
VILL- BAJABERIA, PO- SRIKRISHNAPURE
[Y] Unreserved (UR) [ ] Scheduled Caste (SC)
DIST- PURBAMEDINIPUR
[ ] Scheduled Tribe (ST) [ ] Other Backward Class
(OBC)
City/State: PURBAMEDINIPUR , WEST BENGAL
7. b) Sub-Category
Pincode: 721659 , Landline No:
[ ] Ex-Service Man (ESM) [ ] Govt. Servant (GS)
[ ] Meritorious Sports [ ] Widow/Divorcee c ) Mobile No
Person (MSP)
+91 - 8093388278
[ ] Persons with Disability (PWD) d ) Email
[ ] Orthopaedically [ ] Hearing Impaired (HI) samirbera11@gmail.com
Handicapped (OH)
[ ] Visually Impaired (VI)

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

Qualification Main Subjects / Trade University / Board Year of Duration Maximum Marks % of Marks
(Specify Subject / Trade Passing of Course Marks Obtained / Secured
as mentioned on the (In years) CGPA
Certificate / Degree of
EQR)
X NA WEST BENGAL 2006 NA 800 574 71.75
BOARD OF
SECONDARY
EDUCATION
XII
ITI
B.Sc
Diploma CIVIL ENGINEERING WEST BENGAL 2011 3 5500 4529 82.34
STATE COUNCIL OF
TECHNICAL
EDUCATION
Grad.
PostGrad.
OTHERS1
OTHERS2

12. b) Higher Education

 Have you Completed or persuing M.Sc./B.Tech./B.E. degree etc.? YES [ ] NO [ Y ]
Institute Name Qualification Likely Date/Date of Completion
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

API 50.00 2014-10-03 10:42:11 28881717 73438778 Processed

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

Name of Organization Post Held Pay Scale / Period From Period to Nature of Duties
Grade Pay Performed

15. Important Endorsements

a) (i) Type of ID Proof : VOTER ID CARD ID No.: ZQD1423094

(ii) Height (cm) : 165 Weight (kg) : 75
Identification Mark : A CUT MARK IN LEFT LEG
(iii) Driving License :
(ii ) Two / three Wheelers:
(i ) LMV :
(i ) HMV :

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

Name of Unit Rank Date of Date of CO Name Contact NO.

Joining Discharge

16. Other relevant information (If any)

17. Declaration
I SAMIR BARAN BERA son/Daughter of RANAJIT BERA 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/appointment is liable to be cancelled.

18.

a) Left Hand Thumb Impression b) Signature of Candidate

Place :

Date :

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 this
Online 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 post
applied.

ONLINE APPLICATION NUMBER : 90104001950 , Printed On Date :3 / 10 / 2014 10:48:11