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107 - A
D IPR Questionnaire No. 107- A (Revised)

PERSONAL INFORMATION QUESTIONNAIRE O.I.R. .

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

Name in CAPITALS (As in the matriculation certificate) __________________________________________________________________

Father’s Name __________________________________________________________________

(a)
Place of Maximum Residence (Place, District, State)
(with approximate population of the place) __________________________________________________________________
(b)
Place of Present Residence (Place, District, State)
(with approximate population of the place) __________________________________________________________________
(c)
Place of Permanent Residence (Place, District, State)
(with approximate population of the place) __________________________________________________________________
(Whether District HQ or not) __________________________________________________________________

Fill in the details below :-

State & District Religion Whether SC ST OBC Mother Tongue Date of Birth Married Single Widower

(a) ? Parents Alive Yes / No

(b)
If not alive, your age at the time of Mother’ s / Father’s death __________________________________________________________________
(c) Parents’ / Guardian’s and Siblings’ Occupatio n/ income (as applicable) :-

Particulars Education Occupation Income per month

Father
Mother
Guardian
Elder Brother Sister
Elder Brother Sister
Younger Brother Sister
Younger Brother Sister

Educational Record (commencing from Matriculatio n / Equivalent Examination) :-

Qualification Full Name of Board Year Div. Medium of Boarder Day Outstanding
acquired Institution University & Marks % Instruction Scholar achievement, if any

Matric Hr. Sec.

10+2
10+2 Equivalent

Graduation

Post-Graduation
Professional

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/ Age ( Years & Months) / Height (in Metre) / Weight (in Kilogram)
______________________________________ _____________________________ __________________________________

Present Occupation and personal monthly income, if any ______________________________________________________________________________

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

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

Total Training Wing Division Certificate Obtained

(a) Participation in games & sports :-

Period or duration
Games Sports of Participation Represented Outstanding achievement, if any
School / College / University / Other

(b) Hobbies / Interest ______________________________________________________________________________

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

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

(d)
Position of responsiblity/offices held in NCC/Scouting ______________________________________________________________________________
Sports Team/Extra-curricular group and other fields ______________________________________________________________________________

(a) Nature of Commission

(b) Choice of Service

Number of chances availed for commission in all three Services ______________________________________________________________________________

Details of all previous interviews, if any (Army Navy Air Force Selection Boards)

Date
Sl. No. Type of Entry SSB No. & Place Chest No. Batch No.

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