CONFIDENTIAL

DIPR Questionnaire No. 107-A (Revised)

PERSONAL INFORMATION QUESTIONNAIRE

O.I.R._______________

1. Selection Board (No. & Place) Batch No. Chest No. UPSC/Other Roll No.

2. Name in capital (As in the application form) _______________________________________

3. Father Name _______________________________________

4. (a) Place of Maximum Residence (Place, District, State) _________________________________

(b) Place of Present Residence (Place, District, State) _________________________________

(c) Place of Permanent Residence (Place, District, State) _________________________________

(Whether District HQ or not) _________________________________

5. Fill in the details below :-

State & District Religion Whether Mother Date of Birth Marries/Single/W

SC/ST Tongue idower

6. (a) Parents alive Yes/No.

(b) If not alive, your age at the time of father/mother’s death _____________________________

(c) Parents/Guardian Occupation/Income (as applicable)

Particulars Education Occupation Income per Month

Father

Mother
Guardian
Elder Brother/Sister
Elder Brother/Sister
Young Brother/Sister
Young Brother/Sister
 7. Educational Record (commencing from Matriculation/Equivalent Examination):-

Qualification Name Of Board/ Year Division & Medium Of Boarder/ Outstanding

Acquired Institution University Marks% Instruction Day Achievement
Scholar if any
Metric/Hr. Sec.

10+2 equivalent

Graduation

Post Graduation
/ Professional

8. Age (Year & Months) Height (In Metre) Weight (In Kilogram)
______________________ ________________________ ________________________

9. Present Occupation and Personal monthly income. If any _________________________________

10. (a) N.C.C. Training Yes /No

(b) If Yes, Total Training (Give details below)

Total Training Wing Division Certificate Obtained

11. (a) Participation in Games & Sports :-

Game/Sports Period of duration of Represented School/ Outstanding

Participation College/ University achievement if any

(b) Hobbies / Interest _________________________________

(c) Participation in extra-curricular, activities :-

Name of the activity group Duration of Participation Outstanding achievement if any

 (d) Position of responsibility/ offices held in NCC / Scouting/ ______________________________

Sport team / Extra-curricular Group and other fields ______________________________

12. (a) Nature of Commission

(b) Choice of Service

13. Number of chances availed for commission in all three Services ___________________________

14. Details of previous interviews, if any (Army/ Navy/ Air Force Selection Boards)

St. No. Type of Entry SSB No. & Date Chest Recommended/
Place No/Batch No. Not
Recommended

15. Metric/ Higher Secondary

Name of Institution (In full, no abbreviations) _________________________________________

Location of Institution(City/Town/Village) Name of Board

__________________________________ (CBSE/ICSE/State Board/Others) ______________

Type of Institution Govt./Private Medium of Instruction

Hindi/English/Regional _______________

Year of Passing__ Overall Percentage of Marks obtained_____ Division____ Day scholar/Boarder

Subject Theory Practicals/ Sessionals Total Outstanding

Achievements
(if any)
Max Marks % Max Marks % Max Marks %
Marks obtained Marks obtained Marks obtained

Total
 16. Senior Secondary / 10+2 / Equivalent

Name of Institution (In full, no abbreviations) _________________________________________

Location of Institution(City/Town/Village) Name of Board

__________________________________ (CBSE/ICSE/State Board/Others) ______________

Type of Institution Govt./Private Medium of Instruction

Hindi/English/Regional _______________

Year of Passing__ Overall Percentage of Marks obtained_____ Division____ Day scholar/Boarder

Subject Theory Practicals/ Sessionals Total Outstanding

Achievements
(if any)
Max Marks % Max Marks % Max Marks %
Marks obtained Marks obtained Marks obtained

Total

17. Graduation

Name of Institution (In full, no abbreviations) _________________________________________

Location of Institution(City/Town/Village) ________________________________________

University ______________________________________________________________________

Course B Tech/ B E / B Sc / B.com / B A Branch / Stream

__________________________

Year of Admission _______Pursuing/Completed Year of completion _______ Day scholar/Boarder

Medium of Instruction Hindi/English/Regional __________ Division____ Aggregate percentage___

 Year/ Theory Practicals/ Sessionals Total Outstanding
Semester Achievements
(if any)
Max Marks % Max Marks % Max Marks %
Mark obtained Marks obtained Marks obtained
s
1
2
3
4
5
6
7
8
Total

18. Post Graduation

Name of Institution (In full, no abbreviations) _________________________________________

Location of Institution(City/Town/Village) ________________________________________

University ______________________________________________________________________

Course B Tech/ B E / B Sc / B.com / B A Branch / Stream __________________________

Year of Admission _______Pursuing/Completed Year of completion _______ Day scholar/Boarder

Medium of Instruction Hindi/English/Regional __________ Division____ Aggregate percentage___

Year/ Theory Practicals/ Sessionals Total Outstanding

Semester Achievements
(if any)
Max Marks % Max Marks % Max Marks %
Marks obtained Marks obtained Marks obtained
1
2
3
4
5
6
7
8
Total