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APPLICATION FORM FOR Short S ervice Commis sion - Universi ty Entry
Scheme(Electrical) Jun 14 BATCH
(UNMARRIED MALE/ FEMALE CANDIDATES ONLY)
FOR INDIAN NAVY OFFICE USE ONLY
CODE
NO.VALIDITY STATUS APPLICATION NO -SUL144212022
Valid Invalid
1. CHOICE OF ENTRY- [1] SSC(UES-ELE) [4] SSC(UES-PILOT ) [3] SSC(UES-
OBSERVER) [2] SSC(UES-SUB ELE)
2. P ERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:-
NAME SUDARSHAN R NATIONALIT Y:INDIAN
FATHER'S NAME Ramesh FATHER'S OCCUPATION/DESIGNATION:Private service
DATE OF BIRTH 1992/05/24 DOMICILE:Tami ln adu
GENDER Male MARITIAL STATUS:Unmarried
7 . ADDRESS: CORRESPONDENCE ADDRESS PERMANENT ADDRESS
ADDRESS AV hostel s, room no 199M-213 Avalapalli Hudco Basthi road.Near
GKD Nagar
DISTRICT Thanjavur Krishnagiri
STATE Tamilnadu Tamilnadu
PINCODE 613401 635109
TELEPHONE 04344 - 240203 04344 - 240203
MOBILE 9150421064 --NA--
EMAIL [email protected] --NA--
8.EDUCATION PARTICULARS:
8(a).Qual/Stream/YOP: Final year B.Tech / Electronics
and Communication / 2014
Aggregate Grade (range - 1 to 10): 7.777Percentage
78.77%
Maximum Marks Marks Obtained Maximum Marks Marks Obtained
1st Semester 10 7.4375 2nd Semester 10 8.5152
3rd Semester 10 7.8966 4th Semester 10 7.5667
5th Semester 10 7.9667
9.NAME AND ADDRESS OF COLLEGE WHERE STUDIED :SASTRA UNIVERSITY SASTRA UNIVERSITY
THIRUMALAISAMUDRAM THANJAVUR
10.NAME OF UNIVERSIT Y T O WHICH COLLEGE AFFILIAT ED AND ADDRESS:SASTRA UNIVERSITY
11. COLLEGE STATE:Tamilnadu
12. I HAVE NOT ATTENDED ANY SSB TILL TO DATE WITH THE ARMY/NAVY OR THE AIR FORCE.
13.Details of service under central/stat e Govt . if any (Candidates already in service should apply through proper channel and
obtain NOC from the present employer.):NIL
14.APPLICATION FORM TO BE SIGNED BY THE DIRECTOR O F ENGINEERING C OLLEGE/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.
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
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7/26/13 Untitled Document
nausena-bharti.nic.in/th_officer_ues_campus.php?applicationno=SUL144212022
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