APPLICATION FORM FOR Short Service Commission - University Entry Scheme(Pilot) Jun 15

BATCH
Please paste your
recent passport-size
photograph here
(UNMARRIED MALE/ FEMALE CANDIDATES ONLY)
FOR INDIAN NAVY OFFICE USE ONLY

CODE
NO.
VALIDITY
STATUS
APPLICATION NO-SUP152203943

Valid
Invalid


1. CHOICE OF ENTRY- [2] SSC(UES-ELE) [1] SSC(UES-PILOT) [4] SSC(UES-
OBSERVER) [3] SSC(UES-SUB ELE)
2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:-
NAME
SUMIT
SHRIVASTAVA
NATIONALITY: INDIAN
FATHER'S NAME
rajesh
shrivastava
FATHER'S
OCCUPATION/DESIGNATION:government
emploee
DATE OF BIRTH 1993/09/25 DOMICILE: Madhya Pradesh
GENDER Male MARITIAL STATUS:Unmarried

3. ADDRESS: CORRESPONDENCE ADDRESS PERMANENT ADDRESS
ADDRESS
H.NO 2230/1 new kanchanpur
adhartal jabalpur
H.NO 2230/1N.C new kanchanpur
adhartal jabalpur
DISTRICT new kanchanpur post office jabalpur
STATE Madhya Pradesh Madhya Pradesh
PINCODE 482004 482004
TELEPHONE - -
MOBILE 9993780734 --NA--
EMAIL sumit99937@gmail.com --NA--
4.EDUCATION PARTICULARS:
4(a).Qual/Stream/YOP: Final year B.E / Electronics and Communication / 2015
Aggregate Grade (range - 1
to 10): 7.46
Percentage 74.62%

Maximum
Marks
Marks
Obtained
Maximum
Marks
Marks
Obtained
1st
Semester
10 7.67
2nd
Semester
10 7.13
3rd
Semester
10 7.50
4th
Semester
10 7.38
5th
Semester
10 7.63

5.NAME AND ADDRESS OF COLLEGE WHERE STUDIED : shri ram institute of science and technology near ITI madhotal
6.NAME OF UNIVERSITY TO WHICH COLLEGE AFFILIATED AND ADDRESS: RGPV
7. COLLEGE STATE:Madhya Pradesh
8. I HAVE NOT ATTENDED ANY SSB TILL TO DATE WITH THE ARMY/NAVY OR THE AIR FORCE.
9.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.):no

APPLICATION FORM TO BE SIGNED BY THE DIRECTOR OF ENGINEERING COLLEGE/HEAD OF DEPARTMENT
Certified that Miss/Mr. ................................................................................... is studying in this Univeristy/ College/ Institute and that
details furnished by him in paras 3 and 4 of the application form have been checked with reference to relevant records and found
correct.
Place : ...................... Date: ..................
Signature (Director/ HOD):
.....................................
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 examination. 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: ..................
Signature
of
Applicant: