DIPR Questionnaire No.
107-A (Revised-2023)
PERSONAL INFORMATION QUESTIONNAIRE O.I.R.
1. 6HOHFWLRQ%RDUG Batch No. & Entry Chest No. UPSC/ Other Roll No.
1R 3ODFH
18 SSB(E) - ALLAHABAD 38846 - Short Service SSCW(Tech)-36/750706
Commission Technical
Women
2. Candidate Name Dimpal Dubey
3. Father/Guardian Name Sanjay Dubey
4. Mother's Name Pramila Dash
5. (a) Place of Present Residence (District & State) with BHUBNESWAR,Khordha,Odisha
approximate population of place) 1321000
(b) Place of Permanent Residence (District & state) TITILAGARH,Balangir,Odisha
(With Approximate population of place) 34067
(whether District HQ or not ?): No
(c) Place of Maximum Residence(Place, District & State) Bhubneswar-Khordha,Odisha,
With approximate population of place) 1321000
6. Fill in the details below:
State & District Religion Whether SC/ST/OBC Mother Tongue Date of Birth Marital Status
Balangir, Odisha Hindu General Oriya 29-01-2002 Unmarried
7. (a) Marital Relationship of Parents Separated
(b) Your age at time of Separation/Divorce 15
(c) Staying with? Mother
(d) Parents alive? Father : No Mother:Yes
(e) if not alive, your age at time of Mother's/Father's Death. Father :15.00 Mother:NA
(f) Parent's/Guardian's and Siblings' Occupation/Income (as Applicable)
Particulars Education Occupation Income per Month
Mother HSC Hostel Warden 20000.00
8. Educational Record (Commencing from Matriculation/Equivalent Examination)
Qualification Stream Full Name Board/Univ Year Div & Medium of Boarder/ Outstanding
acquired of Institute ersity Marks % Instruction Day Achievement
Scholar
Matric General Saraswati HSC 2017 First Oriya Boarder Nil
Shishu 71.00
Vidya
Mandir,
Titilagarh
10+2 Electrical Centurion University 2020 First English Boarder Nil
University 72.00
Of
Technology
And
Manageme
nt
B.E./B.Tech/B.Ar Instrume Odisha University 2024 First English Boarder Nil
ch/Msc ntation University 79.00
Computer And Of
Electroni Technology
cs And
Research
9. Age (Years & Months) Height (in Metre) Weight (in Kilogram)
23.5 1.68 49
10. Present and Past Occupation and personal monthly
income
Present Student Rs 00
Past Customer Service Rs 12000
11. (a) NCC Training No
(b) If Yes, Total Training (Give details below):
12. (a) Participation in Games and Sports
Games/Sports Duration Represented School/ Outstanding
of Participation College/University/other Achievement
Essay Competition
(b) Hobbies/Interest Reading, Dancing, Making
Illustrations
(c) Participation in Extra Curricular Activities
Name of Activity Group Duration of Participation Outstanding Achievment
Dance Competition 2019 Third Position
(d) Position of responsibility held in NCC/Scouting/ Sports and Extra - Volunteering, Event Organizer
curricular activities and other fields
13. (a) Nature of Commission: Short Service Commission
(b) Choice of Services: Army
14. Number of chances availed for commission in all Four Services. 0
15. Detail of all previous interviews, if any (Army/Navy/Air Force/Coast Guard Selection Boards)
*This is certify that all the personal information given above by me is correct and true*
Candidate Signature
