APPLICATION FOR GRANT OF PERMANENT COMMISSION IN NAVAL

ARMEMENT INSPECTION CADRE OF EXECUTIVE BRANCH

Regd No. ....................................... (For Official use only)

1. Applying for course: PC NAIC JULY-2011

2. Name in BLOCK capitals as in Matriculation certificate: - SIDDHARTH TIWARI

3. Expanded full name if abbreviated in Sl. 2 above: - SIDDHARTH TIWARI

4. Father's name as in your Matriculation certificate: - KESHAV KUMAR TIWARI

5. Father's Occupation/Designation: PRIVATE SERVICE

6. Permanent Address:-
JR 207
HINDALCO COLONY
HINDALCO INDUSTRIES LIMITED
RENUKOOT, SONEBHADRA (UP)

District: SONEBHADRA

State: UTTAR PRADESH

PIN: 231217

Mobile: 9532988062

7. Correspondence Address:-
JR 207
HINDALCO COLONY
HINDALCO INDUSTRIES LIMITED
RENUKOOT, SONEBHADRA (UP)

District: SONEBHADRA

State: UTTAR PRADESH

PIN: 231217

Mobile: 9532988062

Email: Siddharth.tiwari@live.com

8. Nationality: - INDIAN

9. Domicile: - NOT APPLICABLE

10. Date of Birth: - (DD/MM/YYYY): 30/03/1988

11. Marital Status: - Unmarried

12. Details of marks secured in Graduation and above:-

Semester/Year wise Marks secured

Exam Passed
Semester/Year Maximum Marks % of Marks
Marks Obtained
1 0 0 0 6 6 1 6 6
BACHELOR OF I
TECHNOLOGY 1 0 0 0 7 6 6 7 7
IN II
ELECTRONICS
AND 1 0 0 0 7 0 6 7 1
COMMUNICATIONS III
ENGINEERING. 1 0 0 0 6 4 7 6 5
IV
1 0 0 0 6 1 8 6 2
V

1 0 0 0 6 2 2 6 2
VI
1 0 0 0 6 9 9 7 0
VII
1 0 0 0 7 4 7 7 5
VIII

Total Marks & overall Percentage 8000 68.35 %

13. Specify stream during BE/BTech: ELECTRONICS

14. Name of College where studied and address:

INSTITUTE OF TECHNOLOGY AND MANAGEMENT
AL-1, SECTOR-7, GIDA, GORAKHPUR-273209

15. Name of University to which college affiliated and address:

UTTAR PRADESH TECHNICAL UNIVERSITY
(now Gautam Buddha Technical University)
LUCKNOW, UTTAR PRADESH.

16. Have you attended any SSB interview earlier: (If yes, give details for all earlier attempts)
Service Type of entry Name of SSB Month & Year of SSB Batch No. Rec/Not
Rec.
Army STL-35 19 SSB, ALD July, 2010 DSTL-65987(ABS) NR
Air Force 78-AEC 4 AFSB, BSB September, 2010 NR

Air Force 77-AEC 1 AFSB, DDN March, 2010 NR

17. Details of service under central/state Govt., if any NOT APPLICABLE

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.

Place: RENUKOOT Signature

Date: 2nd November 2010 Name of the Applicant: Siddharth Tiwari