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APPLICATIO N FO RM FO R Short Se rvice Commission - Unive rsity Entry Sche me (Ele ctrical) Jun 14 BATCH (UNMARRIED MALE/ FEMALE CANDIDATES O NLY) FO R INDIAN NAVY O FFICE USE O NLY CO DE NO . VALIDITY STATUS APPLICATIO N NO -SUL141205470

Valid

Invalid

1. CHOICE OF ENT RY- [1] SSC(UES-ELE) [2] SSC(UES-PILOT ) [3] SSC(UESOBSERVER) [4] SSC(UES-SUB ELE) 2. PERSONAL PART ICULARS AS IN MAT RICULAT ION CERT IFICAT E:NAME FAT HER'S NAME DAT E OF BIRT H GENDER 7. ADDRESS: ADDRESS DIST RICT ST AT E PINCODE T ELEPHONE MOBILE EMAIL SHAILESH KUMAR RISHIPAL BALIYAN 1991/11/09 Male NAT IONALIT Y: INDIAN FAT HER'S OCCUPAT ION/DESIGNAT ION:SERVICE DOMICILE: Uttar Prade sh MARIT IAL ST AT US:Unmarrie d PERMANENT ADDRESS RO O M NO -234JSS BO YS HO STEL C20/1SEC-62NO IDA GAUTAM BUDDH NAGAR Uttar Prade sh 201301 --NA---NA--

CORRESPONDENCE ADDRESS RO O M NO -234JSS BO YS HO STEL C20/1SEC-62NO IDA GAUTAM BUDDH NAGAR Uttar Prade sh 201301 8860817235 coolshail09@gmail.com

8.EDUCAT ION PART ICULARS: 8(a).Qual/Stream/YOP: Final ye ar B.Te ch / Ele ctronics and Communication / 2014 Maximum Marks 1st Semester 3rd Semester 5th Semester 1000 1000 1000 Marks O btaine d 708 726 710

Percentage 71.3% Maximum Marks 2nd Semester 4th Semester 1000 1000 Marks O btaine d 700 721

9.NAME AND ADDRESS OF COLLEGE WHERE ST UDIED : JSSATE NO IDA C-20/1 SEC 62 NO IDA 10.NAME OF UNIVERSIT Y T O WHICH COLLEGE AFFILIAT ED AND ADDRESS: MAHAMAYA TECHNICAL UNIVERSITY NO IDA 11. COLLEGE ST AT E:Uttar Prade sh 12. I HAVE NOT AT T ENDED ANY SSB T ILL T O DAT E WIT H T HE ARMY/NAVY OR T HE AIR FORCE. 13.Details of service under central/state Govt. if any (Candidates already in service should apply through proper channel and obtain NOC from the present employer.):14.APPLICATIO N FO RM TO BE SIGNED BY THE DIRECTO R O F ENGINEERING CO LLEGE/HEAD O F DEPARTMENT Certified that Miss/Mr.....................is studying in this Univeristy/ College/Institute and that details furnished by him in para 7 and 8 of the application form have been checked with reference to relevant records and found correct. Signature (Director/ HOD): Place : ...................... Date: .................. .....................................
DECLARATION 1.I, hereby declare that I am unmarried male/female, governed by nationality condition as laid down by the Government of India and have never been debarred from appearing at any ex amination. I have never been arrested/prosecuted and convicted by a criminal court or involved in any other case registered by the Police. 2. I, hereby, solemnly declare that all the statements made in the above application are true and correct to the best of my knowledge and belief. 3. I, fully understand that in the event of any information being found false or incorrect, appropriate action can be taken against me. 4.Eligibility criteria will be verified on reporting at the selection centres. If found ineligible, I understand that criminal proceedings can be initiated against me for fraudulent entry and falsification of documents. I also accept that no TA/DA will be admissible to me in such cases.

Note : The copy of the application form is to be submitted to the Campus Selection Team of Indian Navy at the time of Campus Interview.The
date and time of interview will be intimated.

Place : ...................... Date: ..................

nausena-bharti.nic.in/th_officer_ues_campus.php?applicationno=SUL141205470

Signature of Applicant:

July 12, 2013, 7:27 pm

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