Application Form 901040000624

Advt. No. CEPTAM-09/STA-B DRDO ENTRY TEST-2018 Crucial date of Eligibility-29-08-2018

For Office Use Only

Online Application Number: 901040000624
Generated On Date: 10/08/2018 02:23 hrs

8. Nationality: INDIAN
9. Identity Proof
1. Post Code & Post Name: [STA-B]-0104-Chemical Type: Aadhaar Card ID Number: 6311 3700 9239
Engineering 10. Gender: Male
2. Exam City Preference:32-MUMBAI, 39-PUNE, 34-NAGPUR
3. Candidate’s Name: ADVALWAR ANKUSH RAMESH 11. Contact Details:
4. Father’s Name: RAMESH
5. Mother’s Name: ANUSAYA a) Correspondence Address: C/O PANDHARI SHIRKE NEAR
6. Date of Birth: 25/08/1997 RAM MANDIR, NAVGHAR
Age as on Crucial Date: 21Y,0M,4D District: Raigad City: LONERE
State: MAHARASHTRA Pincode: 402103
7.a) Category
[ ] Unreserved(UR) [ ] Scheduled Caste (SC) (if Permanent Address same as Correspondence Address) [ ]
[ ] Scheduled Tribe (ST) [ ] OBC (Creamy Layer) b) Permanent Address: NEAR HANUMAN TEMPLE WARD
[ ] OBC (Non-Creamy Layer) NO. 2
District: Yavatmal City: PATANBORI
(if ST/SC/OBC-NCL) State: MAHARASHTRA Pincode: 445305
Certificate no: 40902136931 Date of issue: 29/06/2018
c) Mobile No: 9604746481
State: MAHARASHTRA Sub Caste type: Beldar, Muslim Beldar, d) Alternate No: 8208364974
Od
e) Email ID: advalwarankush@gmail.com

12. Essential Qualifications

a) Do you possess EQR as per CEPTAM-09/STA-B Advt. (Diploma /B.Sc.) as on crucial date of eligibility: YES[ ] NO [ ]
b) Do you possess B.Sc./Diploma/Both : B.Sc.[ ] Diploma [ ] Both(Diploma and B.Sc.)[ ]

Mode of
University/ Year of Max. Marks/ Marks/ CGPA % of Marks
Qualification Degree/ Main Subject Roll No.
Board Passing CGPA obtained Secured
Qualification
MATHS
X Regular H162366 MSBSHSE 2013 500.00 410.00 82.00
SCIENCE
PC MOP FM
Diploma Regular 435237 MSBTE 2016 1650.00 1244.00 75.39
HT CRE MT
c) Subject mentioned on EQR: CHEMICAL ENGINEERING
d) Higher Qualification (B.E., B.Tech, M.Sc, M.Tech, Ph.D., etc)
Are you Pursuing YES[ ] NO [ ] Have you Completed YES [ ] NO [ ]
Degree Likely Date of Completion Degree Likely Date of Completion
B.Tech 01/06/2019 NA NA
13. a) Details of Application Fee of Rs. 100/- Paid (If not exempted as per Govt. rules)

Payment Method Fee Amount Payment Date Payment ID Transaction ID Status

APTC0019584720180 201808101112128001
DC 100.00 10/08/2018 TXN_SUCCESS
810022233 10168105733295705
14. Physical Measurements:
a) Height (cm): 170.00 b) Weight(kg): 55.00 c) Visible Identification Mark: ROUND BIRTH MARK ON FOREHEAD
15. Special Categories (if any) :
a) Do you belong to Minority community: YES [ ] NO [ ]
b) Domiciled in J&K during 01/01/1980 to 31/12/1989 : YES[ ] NO [ ]
c) Defence Personnel with Disability: YES [ ] NO [ ]
16.Posting Preference

Preference 1 2 3 4 5 6
Location
P2 N1 H2 V1 A3 J1
(City Code)
17.List of Documents Uploaded
10th class or equivalent Certificate , Caste Certificate , EQR Certificate
I hereby give my consent to disclose my particulars, score and rank of examination publically (refer 5.2 of CEPTAM-
09/STA-B Advertisement) on the website. YES [ ] NO [ ]
18. Declaration
I ADVALWAR ANKUSH RAMESH son/daughter of RAMESH hereby declare that
a) I have read and understand 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.
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/recruitment, my candidature/recruitment/ appointment is liable to be cancelled.
19. Required at the time of document verification, 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 CEPTAM/DRDO at this time. However, it is advised to
keep this application form and copy of the advertisement for claiming travel concession from railways, and also for future
references. CEPTAM does not undertake any detailed 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: 901040000624 , Generated on 10/08/2018 02:23 hrs