APPLICATION FORM FOR Short Service Commission - University Entry Scheme(Observer) Jul 14 BATCH (UNMARRIED MALE CANDIDATES ONLY)

FOR INDIAN NAVY OFFICE USE ONLY CODE NO. VALIDITY STATUS APPLICATION NO-SUO131202232

Valid

Invalid

1. CHOICE OF ENTRY- [4] SSC(UES-NA) [5] SSC(UES-ENG) [3] SSC{UES-GS(X)} [2] SSC(UES-PILOT)[1] SSC(UESOBSERVER) 2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:NAME FATHER'S NAME DATE OF BIRTH GENDER ashish srivastava ashok kumar srivastava 09/05/1992 Male NATIONALITY: INDIAN FATHER'S OCCUPATION/DESIGNATION:advocate DOMICILE: Uttar Pradesh MARITIAL STATUS:Unmarried

7. ADDRESS: ADDRESS DISTRICT STATE PINCODE TELEPHONE MOBILE EMAIL 8.EDUCATION PARTICULARS:

CORRESPONDENCE ADDRESS 6/405vikas nagar lucknow lucknow Uttar Pradesh 226022 9780206257 ashishsrivastava923@gmail.com

PERMANENT ADDRESS 6/405vikas nagar lucknow lucknow Uttar Pradesh 226022 --NA---NA--

8(a).Qual/Stream/YOP: Pre Final Year B.Tech / Mechanical / 2014 Maximum Marks 1st Semester 3rd Semester 100 100 Marks Obtained 83.61 68.85

Aggregate Grade (range - 1 to 10): 8.68Percentage 77.97% Maximum Marks 2nd Semester 100 Marks Obtained 81.45

9.NAME AND ADDRESS OF COLLEGE WHERE STUDIED : lovely professional university phagwara 10.NAME OF UNIVERSITY TO WHICH COLLEGE AFFILIATED AND ADDRESS: jalandhar 11. COLLEGE STATE:Punjab 12. I HAVE NOT ATTENDED ANY SSB TILL TO DATE WITH THE ARMY/NAVY OR THE 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.):none 14.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 para 7 and 8 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: .....................................

September 28, 2012, 1:20 am