APPLICATION FOR 77 AEC (MEN)/49 (WOMEN)

COURSES COMMENCING IN JULY 2010

FOR OFFICE FOR AFSB USE

USE
APPLICATION BRANCH AFSB CODE NO. CHEST NO.
NO.

1.NAME IN BLOCK CAPITAL AS IN MATRICULATION CERTIFICATE

2. FATHERS NAME AS IN MATRICULATION CERTIFICATE

3. PERMANENT ADDRESS WITH PIN CODE AND TELE NO. IF ANY

4. PRESENT ADDRESS WITH PIN CODE AND TELE. NO. IF ANY

5. choice of EKT center 1.___________________________

2.________________________________
6. DATE OF BIRTH (DD/MM/YY)

7. MARITAL STATUS: SINGLE/MARRIED/WIDOWER/WIDOW/DIVORCEE

8. SEX- MALE/FEMALE

9. E-mail:
______________________________________________________________________________

10. VISIBLE IDENTIFICATION MARK: _________________________________________________

11. EDUCATIONAL QUALIFICATION

a) Technical qualification (BE/B.Tech )__________________________________________

b) Name of College & Place __________________________________________________
c) Name of university _______________________________________________________
d) Engineering discipline_____________________________________________________
e) Likely date of final result (For appearing students)
f) Semester / Year wise marks:
g) Details of present backlog if any
_________________________________________________
Semest Maximu Marks % of Semest Maximu Marks % of
er/ m Obtaine Marks er m Marks Obtaine Marks
Year marks d d

h) Details of present backlog if any

_________________________________________________

1. I hereby declare that all the statements made in the application are true
to the best of my knowledge and belief.
2. I have never been debarred from appearing in any examination nor, I have
ever been withdrawn from defence training establishments on disciplinary
grounds, nor have I ever been arrested, procecuted or convicted by
criminal court or involved in any other case registered by the police.
3. I undertake not to make any claim for compensation if at any stage of my
selection , my ineligibility for candidature is detected & my candidature is
cancelled as a result thereof.
4. This is the only application submitted by me fo 77 AEC (men)/49
(women) course.
5. Any willful misrepresentation of facts & concealment of facts of
information will result in the cancellation of the candidature and may
debar permanently or for a specified period from applying for the future
courses.

Place___________________

Date____________________
Signature of applicant