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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 -SUL144212022

Valid

Invalid

1. CHOICE OF ENT RY- [1] SSC(UES-ELE) [4] SSC(UES-PILOT ) [3] SSC(UESOBSERVER) [2] 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 SUDARSHAN R Rame sh 1992/05/24 Male NAT IONALIT Y: INDIAN FAT HER'S OCCUPAT ION/DESIGNAT ION:Private se rvice DOMICILE: Tamilnadu MARIT IAL ST AT US:Unmarrie d PERMANENT ADDRESS M-213 Avalapalli Hudco Basthi road.Ne ar GKD Nagar Krishnagiri Tamilnadu 635109 04344 - 240203 --NA---NA-Aggregate Grade (range - 1 to 10): 7.777Pe rce ntage 78.77% Maximum Marks 2nd Semester 4th Semester 10 10 Marks O btaine d 8.5152 7.5667

CORRESPONDENCE ADDRESS AV hoste ls, room no 199 Thanjavur Tamilnadu 613401 04344 - 240203 9150421064 sudarshanr92@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 10 10 10 Marks O btaine d 7.4375 7.8966 7.9667

9.NAME AND ADDRESS OF COLLEGE WHERE ST UDIED : SASTRA UNIVERSITY SASTRA UNIVERSITY THIRUMALAISAMUDRAM THANJAVUR 10.NAME OF UNIVERSIT Y T O WHICH COLLEGE AFFILIAT ED AND ADDRESS: SASTRA UNIVERSITY 11. COLLEGE ST AT E:Tamilnadu 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.):NIL 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
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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: .....................................

July 27, 2013, 10:56 am

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