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Request ID: E-U-2018/5162 E-U-2018/5162

DGCA INDIA CA
Update Profile Form Form 19-07-UPF

GOVERNMENT OF INDIA
DIRECTORATE GENERAL OF CIVIL AVIATION
CENTRAL EXAMINATION ORGANISATION

Computer Number : E-16072430

1. PERSONAL DETAILS

1.1. Name GAUSUL AZAM

1.2. Gender MALE

1.3. Date of Birth 14-08-1997

1.4. Mother's Name SHABNAM KHATOON

1.5. Fathers Name MD. ASLAM

1.6. Email ID suhelasari1995@gmail.com

1.7. Nationality INDIA

1.8. Mobile Number XXXXXX2391

2. Reason for Updation

update address

3. Old Details

Permanent Address S / O - Md Aslam H. No -

148 V. P. O. - Deoria
Distric - DeoriaU. P. -
274001.

4. New Details

Permanent Address vill- malkauli post-deoria

near of katrari choraha
deoria Uttar Pradesh
PIN-274001 India

5. Declaration

I hereby declare that the information provided in this form is correct in every respect to the best of my
❏ knowledge and belief and that nothing has been concealed or withheld by me, I understand that if any
of my particulars/enteries are found false or incorrect before or after the examination, my candidature
shall be rejected and further action can be taken against me by DGCA as deemed fit. Further, I
understand that unutilized fees paid(if any), for previous session(s), will not be adjusted, carried
forward for future examination.

It is an Offence to make, with intent to deceive, any false representation for the purpose of procurring
❏ the grant, issue, renewal or valiation of any certificate, license, approval, permission or other
document. Persons doing so render themselves liable, on summary conviction, to a fine of one lakh
rupees and / or imprisonment for a term not exceeding three months. Further, if renders the person
permanently ineligible to have an Aircraft Maintainance Engineer's License.

I declare that I have read and understood the above declaration.

❏
Online Submission Date & Time : 25/10/2018 & 15:04:07 Page No. 1
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Request ID: E-U-2018/5162 E-U-2018/5162

DATE SIGNATURE

PLACE NAME

6. CERTIFICATION BY COMPETENT AUTHORITY

This is to certify that all the above particulars furnished by GAUSUL AZAM have been verified by me and found to
be correct.

Date: Signature of the

competent authority:

Place: Name & Designation:

(STAMP OF THE AUTH. SIGNATORY)

This certificate to be attested by QM/ DyQM/ TM/ CI/ DyCI/ Chief Engineering Officer in case of serving Defence personnel.

Gazetted officer / Notary Public for PRIVATE unemployed candidate.

* Signature & stamp of the competent authority should partly cover the pasted photograph.

Online Submission Date & Time : 25/10/2018 & 15:04:08 Page No. 2