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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 sudarshanr92@gmail.com --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