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Mhñ vkbZñ ihñ vkjñ iz’ukoyh la[;k 107 - A ¼la’kksf/kr½
D IPR Questionnaire No. 107- A (Revised)
O;fDrxr tkudkjh iz ’ ukoyh
PERSONAL INFORMATION QUESTIONNAIRE vksñ vkbZñ vkjñ @ O.I.R. .

1- p;u cksM Z ¼la[ ;k vkSj L;ku½ cSp lañ pSL V la ñ ;wñ ihsñ ,lñ lhñ ;k vU; jksy uEcj
Selection Board (No. & Place) Batch No. Chest No. UPSC / Other Roll No.

2- lqLiI Vs v{kjks esa uke ¼tSl k eSfVªd izek.k&i= esa gS½

Name in CAPITALS (As in the matriculation certificate) __________________________________________________________________
3- firk dk uke @ Father’s Name __________________________________________________________________

4- (a) vf/kdka’ k le; vkokl dk LFkku ¼LFkku] ftyk] jkT;½ ¼LFkku dh vuqe kfur tula[ ;k lfgr½
Place of Maximum Residence (Place, District, State)
(with approximate population of the place) __________________________________________________________________
(b) orZe ku vkokl dk LFkku ¼LFkku] ftyk] jkT;½ ¼LFkku dh vuqe kfur tula[ ;k lfgr½
Place of Present Residence (Place, District, State)
(with approximate population of the place) __________________________________________________________________
(c) LFkkbZ vkokl dk LFkku ¼LFkku] ftyk] jkT;½ ¼LFkku dh vuqe kfur tula[ ;k lfgr½
Place of Permanent Residence (Place, District, State)
(with approximate population of the place) __________________________________________________________________
¼og ftyk eq[ ;ky; gS vFok ugh½@ (Whether District HQ or not) __________________________________________________________________

5- fuEu fooj.k Hkjsa @ Fill in the details below :-

jkT; vkSj ftyk /keZ vuql wfpr tkfr@ tutkfr ;fn gS ekr` Hkkisk tUe frfFk fookfgr@vfookfgr@fo/kq j
State & District Religion Whether SC @ ST @ OBC Mother Tongue Date of Birth Married@ Single@ Widower

6- (a) D;k ekrk&firk ftfor gS a ? @ Parents Alive gka@ ugha @ Yes / No

(b) ;fn ftfor ugha rks ekrk@ firk dh e`R;q ds le; vkidh vk;q
If not alive, your age at the time of Mother’ s / Father’s death __________________________________________________________________
(c) ekrk&firk@laj {kd vkSj HkkbZ&cgu ds O;olk;@vk; ¼tks ykxw gks½ @ Parents’ / Guardian’s and Siblings’ Occupatio n/ income (as applicable) :-

fooj.k @ Particulars f’k{kk@ Education O;olk;@ Occupation ekfld vk;@ Income per month
firk@ Father
ekrk@ Mother
laj {kd@ Guardian
cM+k HkkbZ@ cgu@ Elder Brother @ Sister
cM+k HkkbZ@ cgu@ Elder Brother @ Sister
NksV k HkkbZ@ cgu@ Younger Brother @ Sister
NksV k HkkbZ@ cgu@ Younger Brother @ Sister

7- ’kSf{kd fjdkMZ ¼eSfVª dq ys’ ku@lEd{k ifj{kk ls vkjEHk djds½ @ Educational Record (commencing from Matriculatio n / Equivalent Examination) :-

izk Ir ;ks x ;rk,s a laL Fkku dk iwjk uke cks M Z @ ;q f uoflZ V h oi s Z Js.kh o vad f’k{kk dk ek/;e Nk=koklh@fnu Nk= vlk/kkj.k mIyfC/k] ;fn
Qualification Full Name of Board@ Year iz f r’kr@ Div. Medium of Boarder @ Day dksb Z gks@ Outstanding
acquired Institution University & Marks % Instruction Scholar achievement, if any

eS f Vª d @ gk;j lSd sa M jh
Matric @ Hr. Sec.

10+2 ds le{k
10+2 Equivalent

Lukrd@ Graduation

Lukrdks R rj @ O;olkf;d
Post-Graduation @
Professional

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8- vk;q ¼oiZs vkSj ekg½ / Age ( Years & Months) mpkabZ ¼ehVj esa½ / Height (in Metre) otu ¼fdyksxzke esa½ / Weight (in Kilogram)
______________________________________ _____________________________ __________________________________

9- orZe ku O;olk; vkSj O;fDrxr ekfld vk;] ;fn gS

Present Occupation and personal monthly income, if any ______________________________________________________________________________

10- (a) jkI Vªs h; dSfMV dksj izf’k{k.k @ N.C.C. Training gka@ ugha @ Yes / No
(b) ;fn gkWa] rks dq y izf’k{k.k ¼fooj.k uhps nks½ @ If Yes, Total Training (Give details below)

dq y izf’k{k.k @ Total Training Lda/ k @ Wing iz H kkx @ Division izkIr ize k.k i= @ Certificate Obtained

11- (a) [ksydwnksa esa Hkkxhnkjh @ Participation in games & sports :-

[ksy @ dz hM+k dk uke Hkkx ysus dh vof/k@ Period or duration Ldw y @dkys t @fo’ofo}ky;@vU; tgk a W vlk/kkj.k fuI ifr]
s ;fn dksb Z gks
Games @ Sports of Participation dk izfrfuf/kRo fd;k @ Represented Outstanding achievement, if any
School / College / University / Other

(b) ’kksd@#fp;ka @ Hobbies / Interest ______________________________________________________________________________

(c) ikB~; fois ;srj lkewfgd dk;Zdykiksa esa Hkkxhnkjh@ Participation in extra-curricular, activities :-

dk;Zd yki lewg dk uke Hkkx ysu s dh vof/k @ Duration of Participation vlk/kkj.k fuI ifr]
s ;fn dksb Z gks
Name of the activity group Outstanding achievement, if any

(d) jkI Vªs h; dSM sV dksj @ LdkmfVax @ [ksy dw n@ ikB~; sRrj vkSj vU; {ks= ksa esa mRrjnkf;Ro dk in
Position of responsiblity/offices held in NCC/Scouting ______________________________________________________________________________
Sports Team/Extra-curricular group and other fields ______________________________________________________________________________

12- (a) deh’ku dk Lo#i @ Nature of Commission

(b) lsok dk p;u @ Choice of Service
1 3 - rhu lsokvksa esa deh’ku ds fy, fdrus ekSds ys pqds gSa &
Number of chances availed for commission in all three Services ______________________________________________________________________________

1 4 - fiNys lHkh lk{kkRdkjksa dk fooj.k] ;fn dksb Z gks ¼vkehZ @ uso h @ ,;j Qksl Z p;u cksM Z½
Details of all previous interviews, if any (Army @ Navy@ Air Force Selection Boards)

dz e la ñ ios’ k dk izd kj ftlds fy, cSB s ,l ñ ,l ñ ch ñ uañ vkSj LFkku rkjh[k @ Date pSLV vkSj cSp uañ
@ Sl. No. Type of Entry SSB No. & Place Chest No. @ Batch No.

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