Appendix ‘A’
(Refer to para 6 of AI 85/74)
APPLICATION FORM FOR THE GRANT OF PERMANENT COMMISSION IN THE
SPECIAL LIST OF THE OFFICERS (QUARTERMASTERS/TECHNICAL/RECORDS)
Category: (i) ASSISTANT EXECUTIVE ENGINEER (AEE B/R)
PART-I
1. (a) No. : JC - 332772 K Rank : NB SUB
(b) Name in full (In Block letters) : RAVINDER KUMAR
(c ) If applying again, exact name as in given : NA
in previous application
(d) Name in full ( In Capital letters as in given in : RAVINDER KUMAR
metric / higher secondary or equivalent cert
(e) Any discrepancies in names in (b), (c) & (d) :NA
above will be explained by given detailed
reason, if necessary on a separate sheet
of paper attached to the application form with
Supporting documents, otherwise candidature
will be cancelled.
(f) Father’s Name : SHRI GOPI CHAND
(g) Religion : HINDU
2. Parent Arm of service : ENGINEERS
3. (a) Unit, Regiment or Corps: : GE (P) NW KARANJA
(b) Unit where serving : NS KARANJA, URAN, NAVI MUMBAI
(c) Postal address in full of the unit where : GE (P) NW KARANJA, NAVAL STN
serving KARANJA, URAN, DIST – RAIGARH,
NAVI MUMBAI
(d) District and State on which the unit where : RAIGARH, NAVI MUMBAI
serving is located
(e) Nearest Railway Station of the unit : CST MUMBAI
(f) Nearest telegraph Office of the unit : URAN, NAVI MUMBAI
Note:- Change of address , if any, should be communicated at once, given particular as showing (b) to (f) above,
to the Directorate concerned at integrated Headquarters of MoD (Army) to whom the application was forwarded by
the applicant’s commanding Officers.
4. Permanent Home Address : ANOOP NAGAR FAZALPUR
PO –ANOOP NAGAR FAZALPUR
PS – KANKHAR KHERA , TEH – MEERUT
DIST – MEERUT, STATE –UTTAR PRADESH
PIN – 250001
5. Date of birth: 01 NOV 1979 (age on next birth day) : 35 YEARS (Matriculation certificate attached)
(Attached matriculation or birth certificate in support)
6. (a) Date of enrolment : 01 NOV 1999
(b) Date of appointment as NCO : 02 NOV 2003
(c) Date of appointment as JCO : 30 APR 2013
(d) Date of emergency commission/ : NA
Temporary commission
(e) Date of short service commission : NA
7. Married or Single : MARRIED
8. Name, address and occupation of next of kin : SMT.BRAJESH
showing relationship (HOUSE WIFE)
ANOOP NAGAR FAZALPUR
PO –ANOOP NAGAR FAZALPUR
PS – KANKHAR KHERA , TEH – MEERUT
DIST - MEERUT, STATE –UTTAR PRADESH
PIN – 250001
9. (a) Have you previously applied for PC(SL) : NO
(b) If so, is this your second or third chance : NA
10. Have you ever appeared before a Service Selection Board for any type of commission? If so, give the
following details of all previous interviews:-
Emergency/ SSC PC PC (SL)
Temporary
(a) Name and place of selection board : NA
(b) Batch No. & Date of interview : NA
(c) Whether recommended for commission : NO
(d ) Have you any relative/intimately known : NA
person serving in any of the selection centre/
Service Selection Board ? If so, give particulars
(e) Have you ever been debarred from appearing : NA
at any examination selection commission
conducted by the Union Public Service
Commission Govt Of India/State Govt/
University/Board or any of educational
Institution/authority ? If so, give details .
Warning:- Concealment of this information may result in the cancellation candidature and may also debar a
candidate either permanent for a specified period from applying for future courses, in addition disciplinary action.
11. Details of Education:-
School or Universities to be given and highest educational standard reached to be stated. No certificates
testimonials or recommendation to be submitted.
(a) 12TH- KK INTER COLLEGE, MEERUT
12. Enter any educational qualification gained after joining the Army : NO
13. (a) Technical (Academic schools/Universities and
Subjects studied to be given and degree/ Diploma recd stated: DIPLOMA IN CIVIL ENGINEERING
IGNOU AT STB (D) BEG & CENTRE
ROORKEE
(b) Technical (Practical):-
(i) Periods of regular apprenticeship service : NO
(ii) Firms in which employed : NO
(iii) Firms main products : NO
(iv) Subject studied : NO
(c) In case where a period of regular apprenticeship was not served but practical training was received
in firm, workshops or University laboratories etc.
(i) Name of the Workshop, Laboratory etc. : NIL
(ii) Subjects studied : NIL
(iii) Period of training : NIL
(d) Technical experience subsequent to (a), (b) & (c) upto the time of joining the Army
(i) Firms or concerns by whom employed : NIL
(ii) Period of Employment : NIL
(iii) Post held and salary received : NIL
(iv) Brief account of type of work (if in control : NIL
of labour, state the Number under your control)
14. Special experience before and since joining the army : NIL
(a) Nature of civil employment, if any : NIL
(b) Staff experience with HQ Army’s/ : NIL
commands etc.
(c) Special technical or military experience during : NIL
active operation.
15. Courses attended since joining the Army : DIPLOMA IN CIVIL
ENGINEERING
16. Give:-
(a) Category of appointment for which you are an : ASSISTANT EXECUTIVE
applicant ENGINEER (AEE B/R)
(b) In order of preference the Arm/Service : ENGINEERS
17. Services in Armed forces:- Here the candidates for quarter masters/ Record officer
appointments should make special reference to there knowledge of rules and regulation
respectively and those for other appointments ( specified in para-I of AI) to there specialized
knowledge and long standing experience connected with the duties of those appointments:-
SL RANK UNIT/FMN APPT HELD PERIOD TIME HELD/YRS
NO. FROM TO MONTH
1. RECT/ No – 2 TRG BN AS A TRAINEE 08 JAN 1999 01 YEAR 11 MONTHS
SPR 21 NOV 2000
2. SPR 66 ENGR REGT CLK GD 21 NOV 2000 01 YEAR 11 MONTHS
20 OCT 2002
3. SPR/NK AGE (I) CLK GD 20 OCT 2002 02 YEAR 08 MONTHS
FAIZABAD 01 JUL 2005
4. NK STB (D) BEG & ATTENDING 01 JUL 2005 02 YEARS 04 MONTHS
CENTRE DIPLOMA 28 OCT 2007
ROORKEE COURSE
4. NK/HAV GE (EAST) JE (CIVIL) 28 OCT 2007 03 YEARS 06 MONTHS
JALANDHAR 22 APR 2011
5. HAV/ GE (P) NW JE (CIVIL) 22 APR 2011 02 YEARS 08 MONTHS
NB SUB KARANJA TILL DATE
(Signature of the applicant)
COUNTERSIGNED
Station : Naval Stn Karanja (Signature of Commanding officer)
Date : Dec 2013
18. Decoration and award held : NIL
19. (a) I hereby declared that to the best of my knowledge in belief the above information is
correct.
(b) In the event of my being granted such a commission, I understand that I am liable to be
appointed to any Arm or Regiment if required by the exigencies of services.
(c) I certified that I am not applicant for a foreign posting and will not volunteer for the same till
the result of my application of PC (SL) is known.
(d) I have been awarded the following punishments under the Army Act.
Punishment Charges for which punishment awarded
NIL NIL
20 (a) Are you an applicant for any other : NIL
category of PC (SL) Commission
(b) If so, state which category : -
(Signature of the candidate)
Unit/ Fmn : GE (P) NW KARANJA Army No. : JC - 332772 K
Place : NAVAL STN KARANJA Rank : NB SUB
Date : Dec 2013 Name : RAVINDER KUMAR
COUNTERSIGNED
Station : Naval Stn Karanja (Signature of Commanding Officer)
Date : Dec 2013
21. Recommendation of CO/OC unit.
Signature :
Name : Suneel Ranaut
Place: Naval Stn Karanja Rank : Lt Col
Date: Dec 2013 Appt : Garrison Engineer
22. Recommendation Technical Advisor (where applicable /suitability for specific Appt applied for to
be recorded)
Signature :
Name : S K Chetty
Place: Rank ; Col
Date: Dec 2013 Appt : CWE Karanja
23. Recommendation and option of Brigade Commander. (or Equivalent)
(ADG or equivalent in case of persons on deputation)
Signature :
Name :
Place: Naval Stn Karanja Rank :
Date: Dec 2013 Appt :
PART-II
(To be completed by Army Medical Officer in the case of applicant)
23. (a) I have today examined the individual named in para- I(No. JC - 332772 K
Rank NB SUB Name- RAVINDER KUMAR above and formed the opinion that he is (give a general
opinion on a degree of the fitness to undergo serve physical and mental strain)
____________________________________________________________________________
____________________________________________________________________________
(b) His medical category is : __________________
(c) His Visual standards are:-
Right : ____________________
Left : ____________________
(d) I have been medical charge of him for __________________________
during which time _________________ he has :-
*(i) Never reported sick.
*(ii) Suffered the normal amount of minor sickness.
*(iii) Complaint of more than the usual amount of casual illness.
*Strike out whichever is NOT applicable.
Place : Naval Stn Karanja
Dated : Dec 2013 (Signature of Medical Officer)
PART-III
(Completion of this part is to be arranged for by the candidate’s OC)
24. Certified that No. . JC - 332772 K Rank: NB SUB Name: RAVINDER KUMAR has satisfactory
record of service and adequate experience for the SL category applied for. He has not been involved in any serious
disciplinary cases, particularly involving morale turpitude and extract of the entries recorded on the character roll is
given below:-
S No. Date of offence Nature of offence Punishment Authority who awarded
Awarded with date punishment
“ Certified that there is no any red ink entry during entire service”
Station: C/O 56 APO
Dated: Dec 2013 (Signature of Commanding Officer)
25. Whether service particulars as entered above by the candidate are correct. if NOT point out the
discrepancies
Station: C/O 56 APO
Dated: Dec 2013 (Signature of Commanding Officer)
Note:- this Para will be filled only in the case of JCO’s/NCO,s
26. I hereby certify that the date of birth shown in Para 5 namely 14 Oct 1974 has been duly verified by me
from the documents detailed below:-
(a) Matriculation certificate or the Secondary School Leaving Certificate recognized by an Indian
university as equivalent to matriculation, or failure that
(b) Municipal Birth Certificate or and extract from the Municipal Birth Register duly certified by
proper authorities are failure that,
(c) The record of admission in the Register of the school or School in which the applicant has
educated and also a record of applicant’s age at various periodical school Examination.
(d) The date of birth of the JCO,s/NCO,s has been determined as laid down in ASI 111/60 from the
apparent age on the enrolment and is 01 NOV 1979 (CORRECT)
Note:- Original Matriculation/equivalent or any other certificates will not be forwarded to integrated HQ of MoD
(Army). This will be returned to the unit concerned where the individual is serving after the verification of date of
birth by the Record office.
Station : C/O 56 APO
Dated : 2013 (Signature of OIC Records)
PART-IV
27 (a) Recommendations and opinion of the Director of Army concerned at integrated Headquarters of
Min of Defence (Army).
(b) Certified that the above candidate possesses/ does not possesses the necessary qualification for the
appointment for which he has applied.
Station: Signature : _____________________
Dated: Designation : _____________________
PART-V
(To be completed by the President, Service Selection Board)
28. Number, Rank and Name of the candidate ___________________________________________________
_________________________________________________________________________________________
29. Batch No. ________________________candidate No. _____________________________________
30. Marks awarded (both in words as well as in figure)_____________________________________________
______________________________________________________________________________________
Signature : __________________
Place: President NO. : __________________
Date: SSB : __________________
ANNEXURE – I
(REFER NOTE TO PARA 17 OF
THE APPLICATION FOR PC (SL)
DETAILS OF EXPERIENCE GAINED DURING THE PERIOD OF SERVICE
ARMY NO. JC – 332772K NB SUB RAVINDER KUMAR
SL RANK UNIT/FMN APPT HELD PERIOD TIME HELD/YRS
NO. FROM TO MONTH
1. RECT/ No – 2 TRG BN AS A TRAINEE 08 JAN 1999 01 YEAR 11 MONTHS
SPR 21 NOV 2000
2. SPR 66 ENGR REGT CLK GD 21 NOV 2000 01 YEAR 11 MONTHS
20 OCT 2002
3. SPR/NK AGE (I) CLK GD 20 OCT 2002 02 YEAR 08 MONTHS
FAIZABAD 01 JUL 2005
4. NK STB (D) BEG & ATTENDING 01 JUL 2005 02 YEARS 04
CENTRE DIPLOMA 28 OCT 2007 MONTHS
ROORKEE COURSE
4. NK/HAV GE (EAST) JE (CIVIL) 28 OCT 2007 03 YEARS 06
JALANDHAR 22 APR 2011 MONTHS
5. HAV/ GE (P) NW JE (CIVIL) 22 APR 2011 02 YEARS 08
NB SUB KARANJA TILL DATE MONTHS
Station: Naval Stn Karanja Signature of the Candidate
No. JC - 332772 K
Date : Dec 2013 NB SUB/JE (CIVIL)
RAVINDER KUMAR
COUNTERSIGNED
Station : Naval Stn Karanja (Signature of Commanding Officer )
Date : Dec 2013
Appendix ‘C’
(Refer to para 5(f) of Army HQ letter No.
08211/PC(SL)/SI/MP-2 dated 17 Jan 2007
LIST OF OFFENCES DEBARRING JCOs/NCOs (INCLUDING L/NKs)
FROM APPLYING FOR PERMANENT COMMISSION (SL)
Ser Section of Army Act Offences
No.
1 34 Offences in relation to the enemy punishable by death
2 35 Offences in relation to the enemy not punishable by death
3 36 Offences punishable more severally on active service
4 37 Mutiny
5 38 Desertion
6 40 (a) Using criminal forces to or assaulting his superior officer
7 41 Disobedience to superior officer (During active operation
only)
8 42 (a) & (b) Insubordination and obstruction
9 43 Fraudulent enrolment
10 45 Unbecoming conduct
11 46 (a) Certain form of disgraceful conduct
12 52 (a), (b), (c), (d), & (f) Offence in respect of property
13 53 Extortion and corruption
14 54 (a) Making away with equipment
15 57 (c ), (d), & (e) Falsifying office document and declaration
16 58 (a) Signing in blank and failure to report
17 64 ( c) & (e) Miscellaneous offences ( attempt to commit suicide and
accepting illegal gratification
Appendix ‘D’
(Refer to para 5(f) of Army HQ letter No.
08211/PC(SL)/SI/MP-2 dated 17 Jan 2007
RECORD OF PARTICULARS
Registered No.________________PC(SL)___________________Quota (to be attached separately)
PART –I
(To be completed by the candidate)
Personal No : JC - 332772 K Rank : NB SUB Name (in full) : RAVINDER KUMAR
Category of SL commission for which applied : : ASSISTANT EXECUTIVE ENGINEER (AEE B/R)
Are you an applicant for any other category of SL commission? : NO
If so, state which
PART-II
Form for checking of previous candidature
(To be completed by the candidate)
Personal No: JC - 332772 K Rank : NB SUB Name (in full) : RAVINDER KUMAR
Date of birth : 01 NOV 1979 Date of enrolment : 08 JAN 1999
Education qualification : (i) 12TH (ii) DIPLOMA IN CIVIL ENGINEERING
Category of SL commission : ASSISTANT EXECUTIVE ENGINEER (AEE B/R)
for which applied
Parent Arm/Service : ENGINEERS
Unit where serving : GE (P) NW KARANJA
Postal address of the unit : GE (P) NW KARANJA, NAVAL STN KARANJA,
DIST – RAIGARH, NAVI MUMBAI
Permanent home address ANOOP NAGAR FAZALPUR
PO –ANOOP NAGAR FAZALPUR
PS – KANKHAR KHERA , TEH – MEERUT
DIST - MEERUT, STATE –UTTAR PRADESH – 250001
Detail of previews interviews/ latest commissioning courses applied for:-
(a ) Course applied for (Name &No.) : NA
(b) SSB Centre : NA
(c) Batch No./Chest No. : NA
(d) Date of interview : NA
(e) Qualified/ rejected : NA
PART-III
(To be completed by CO/OC unit and OIC Records)
Certified that I have checked the criteria as per AI 85/74 as amended and standing instruction
issued by Army HQ vide letter No. 08211/PC (SL)/SI/MP-2 dated 17 Jan 2007.
No. JC - 332772 K Rank NB SUB Name – RAVINDER KUMAR has specialized knowledge or
practical experience connected with the duties of appointment(s) for which he has applied and meets the
laid down criteria for PC (SL)
(i) ASSISTANT EXECUTIVE ENGINEER (AEE B/R) category.
(Signature of CO/OC unit) (Signed by Records)
PART-IV
DETAILS OF PREVIEWS INTERVIEWS LATEST COMMISSIONING
COURSES APPLIED FOR, IF ANY
(For the use of Army HQ)
Type of SSB Centre Batch No./Chest No. Date of interview Qualified/Rejected
Commission
Course No.
Remarks:-
Appendix ‘E
(Refer to para 12 of Army HQ letter No
08211/PC (SL)/SI/MP-2 dated 17 Jan 2007)
CHECK LIST
PRELIMINARY SCREENING – PC (SL) APPLICATION
(To be checked by Controlling Director/Sections at Army Headquarters)
Category applied for :- (i) ASSISTANT EXECUTIVE ENGINEER (AEE B/R)
1. Personal No : JC - 332772 K Rank : NB SUB
2. Trade : JE (CIVIL) Name : RAVINDER KUMAR
3. Unit : GE (P) NW KARANJA Command : SOUTHERN COMMAND
4. Age as on 01 Jul of 2014 year of application : 35 Yrs, 08 Months
5. Date of Birth : 01 NOV 1979
6. Date of enrolment : 08 JAN 1999
7. Does he meet the service limit : YES
8. Educational Qualification :-
(a) Civil : 12TH
(b) Tech (where applicable as required : DIPLOMA IN CIVIL ENGGINEERING
vide AI 85/74)
9. (a) ACR Grading of last one year as per para
5 (a) of this HQ letter No 08211/PC
(SL)/SI/MP-2 dated 17 Jan 2007.
(b) In case ACR not earned specify reason : NA
(c) In case of L/Nks and newly promoted Nks : NA
has Special Report been furnished
10. (a) Disciplinary Case if any : NIL
(b) In case of L/Nks he should have no : NA
red ink entry
11. If meeting experience criteria : ________________________________
(Where application Para 16 of application form)
12. If verified from Record Office : ________________________________
13. If recommended by all fmn HQs (in chain of : _________________________________
Command)
14. Remarks
As per Sheet Roll
As per Sheet Roll/Fd Conduct Sheet and debarring list as per Appendix ‘C’.
Signature
Dy Dir/Jt Dir
Branch/Dte
Army Headquarters
IAFZ-3013
FIELD CONDUCT SHEET
No.: JC - 332772 K Rank : NB SUB Trade : JE (CIVIL) Name: RAVINDER KUMAR
UNIT : GE (P) NW KARANJA
Place Date of Rank Offence Name Punishment Date of By Remarks
Offence of awarded award or whom
witness of order awarded
dispensing
with trial
“Certified that there is no Red/Black ink entry during the entire service of the individual”
Station : Naval Stn Karanja
Dated : Dec 2013 (Signature of CO/OC unit)
( To be completed by CO/OC unit)
Certified that I have been checked the criteria as per AI 85/74 as amended and standing
instruction issued by the Integrated HQ of MoD (Army) letter No. 08211/PC (SL)/SI/MP-2 dated 17 Nov
2007 that No. JC - 332772 K Rank Nb Sub Name: RAVINDER KUMAR held or has the knowledge
or practical experience and is eligible to hold Assistant Executive Engineer related appointments as laid
down criteria for PC (SL) Assistant Executive Engineer category.
Station : Naval Stn Karanja
Dated : Dec 2013 (Signature of CO/OC unit)
POTENTIAL CERTIFICATE
“It is certified that No : JC - 332772 K Rank : Nb Sub Trade JE (CIVIL) Name : RAVINDER
KUMAR is having sufficient potential to work as (i) ASSISTANT EXECUTIVE ENGINEER .
Station : Naval Stn Karanja
Dated : Dec 2013 (Signature of CO/OC unit)
MORAL TURPITUDE CERTIFICATE
“It is certified that No : JC - 332772 K Rank : NB SUB Trade JE (CIVIL) Name : RAVINDER
KUMAR is having High Moral character”.
Station : Naval Stn Karanja
Dated : Dec 2013 (Signature of CO/OC unit)
ELIGIBILITY CERTIFICATE
“It is certified that No : JC - 332772 K Rank : NB SUB Trade JE (CIVIL) Name : RAVINDER
KUMAR is eligible for grant of PC (SL) Commission”.
Station : Naval Stn Karanja
Dated : Dec 2013 (Signature of CO/OC unit)
DECLARATION CERTIFICATE
“No. JC - 332772 K Rank : NB SUB Name: RAVINDER KUMAR Trade : JE (Civil)
of GE (P) NW KARANJA hereby under take that in case the date of birth as shown by me in column 5
of the application form does not tally with the date of birth as entered in my enrolment form, my final
selection subjected to sanction of the competent authority for the rectification of the entry relating to the
date of birth in my enrolment form in accordance with the procedure laid down in Para 138 of the
regulation for the Army as amended vide corrigendum No. 164/VII/68 her to. I further understand the
decision of competent authority in the matter in final”.
Station : Naval Stn Karanja
________________________
Dated : Dec 2013 (Signature of the Applicant)
COUNTERSIGNED
Station : Naval Stn Karanja
Dated : Dec 2013 (Signature of CO/OC Unit)
