Print Date:17-08-2016 04:36 PM

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INDIAN ARMY
Directorate General of Recruiting
SSC(Tech)-48/116747

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Personal Details
1. Roll No
SSC(Tech)-48/116747
2 Course Applied For :
SSC(Tech)-48
3. Candidate's Name (As per Matric
PETHANI BHAVESHKUMAR KISHORBHAI
Certificate)
4. Father's Name
PETHANI KISHORBHAI BAGHUBHAI
5. Mother's Name
PETHANI BHAVNABEN KISHORBHAI
6. Date of Birth (As per Matric Certificate)
15-04-1995
7. Nationality
INDIAN
8. If Other Nationality
9. Marital Status
Unmarried
10. Gender
Male
11. Mobile No
9737498637
12. Email Address
13bcl083@nirmauni.ac.in
13. Permanent Address
14. Correspondence Address
Address
104/darshan
Address
104/darshan
appartment, sweta
appartment, sweta
society, dharam
society, dharam
nagar road , surat nagar road , surat 395008
395008
City / Town / Village surat
City / Town / Village surat
State
Gujarat
State
Gujarat
District
Surat
District
Surat
PIN
395008
PIN
395008
15 SSB Details
(a) Entry
(b) Location
(c) Year/Month
(d) Result
16 Education Details
(a) Type of School
OTHERS

Print Date:17-08-2016 04:36 PM

INDIAN ARMY
Directorate General of Recruiting
SSC(Tech)-48/116747

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(b) Roll No of 10+2 Examination OR Diploma B 166367

(c) Whether Done Diploma
No
(d) Aggregate % of Marks Obtained in Class 90.66
XII
(e) Engineering Stream Applied For
Civil
(f) Specified Stream
Civil Engineering
(g) Date Of Joining Engineering Course
27-07-2013
(h) Date of Completion of Engineering
17-08-2016
(i) Name of College/Institute
nirma institute of technology
(j) Name of University
nirma university
(k) Type of University
Deemed University
(l) State in which University Located
Gujarat
(m) Gate Score
0.00
(n) Valid Upto
17 Marks obtained in PCM in Class XII
Subject
Total Marks
Marks Obtained
Percentage
Physics
100.00
90.00
90.0
Chemistry
100.00
88.00
88.00
Mathematics
100.00
94.00
94.00
Cumulative Percentage
90.67
18. Marks/Grades obtained in Graduation
Semester / Year Total Marks
Marks Scored
% of Marks
Cumulative % of
Marks scored
Semester 1
100.00
77.80
77.80
77.80
Semester 2 /
100.00
78.50
78.50
78.15
Year 1
Semester 3
100.00
80.00
80.00
78.77
Semester 4 /
100.00
87.40
87.40
80.93
Year 2
Semester 5
100.00
87.70
87.70
82.28
Semester 6 /
100.00
85.40
85.40
82.80
Year 3
Note
The universities which have Grade Point system, need to convert Grades into %age of
marks; failing which the application will be rejected.

Print Date:17-08-2016 04:36 PM

INDIAN ARMY
Directorate General of Recruiting
SSC(Tech)-48/116747

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19. Certificates attached with application form:(a)

(b)
(c)
(d)
Declaration
1. I have read and understood the instructions and undertake to abide by them.
2. I hereby declare that all statements made in the application are correct and true.
3. 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.
4. 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.
5. 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.
6. This is the only application submitted for SSC(Tech)-48 and any duplicate application if
detected at any stage, my candidature be cancelled.
7. 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.
8. I have never been withdrawn from NDA, IMA or OTA or any service training academy on
disciplinary grounds.
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.
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 discover that any attempt has been made by me to wilfully
conceal or misrepresent the facts, my candidature may be summarily rejected or employment
terminated.
Place:
Date:17-08-2016

Print Date:17-08-2016 04:36 PM

Signature of Applicant

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INDIAN ARMY
Directorate General of Recruiting
SSC(Tech)-48/116747

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Note
1. After applying online, candidates are requested to take a print out, paste her attested
photograph in the space provided, sign it in blue ink in the space provided and carry the
application without fail along with the original certificates the certificate from the college
principal regarding conversion of cumulative grade in %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, her
candidature will be cancelled.(No need to send printout of application to Recruiting
Directorate).
(a) 2 sets of photocopy of DOB/Matriculation Certificate.
(b) 2 sets of photocopy of Education Qualification Certificate/Marksheets.
(c) 2 sets of photocopy of the valid ID proof.
(d) 20 copies of self attested PP size photograph will also be carried alongwith
the application form.
2. It may be noted that depending upon the total number of applications received by this
office,(Recruiting Directorate reserves the right to short list and to fix cut off
percentage of marks for SSB interview). No representation will be entertained in this
aspect.
3. It may be Noted that candidates must apply strictly as per the notify stream of
Engineering as per Para 3 of Notification and equivalent stream are not allowed /
permitted .
4. Any wrong details filled in above application will lead to cancellation of the candidature
and suitable action will be taken against the Candidate.
5. Submission of multiple applications for SSC(Tech)-48 will lead to cancellation of
candidature.
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/lnstitute and
her final year/semester examinations will be over by _______________________(Date) .

Print Date:17-08-2016 04:36 PM

INDIAN ARMY
Directorate General of Recruiting
SSC(Tech)-48/116747
Place:______________
Date: _______________

Signature:______________
Designation:______________

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