10/2/2014 Untitled Document

http://www.nausena-bharti.nic.in/th_officer_ues.php?applicationno=TPhs8Ruz52yYv730A23M7Yup60A09TM7A3l36P120A23MT98OP7Yup6Q5YUp 1/1
APPLICATION FORM FOR Short Service Commission - University Entry Scheme(GSX) Jun
15 BATCH
Please paste your recent
passport-size photograph
here
(UNMARRIED MALE/ FEMALE CANDIDATES ONLY)
FOR INDIAN NAVY OFFICE USE ONLY
CODE NO. VALIDITY STATUS APPLICATION NO-SUX154201658
Valid
Invalid
1. CHOICE OF ENTRY- [1] SSC{UES-GS(X)} [2] SSC(UES-OBSERVER)
2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:-
NAME
SACHIN
VARGHESE
NATIONALITY: INDIAN
FATHER'S NAME VARGHESE B T
FATHER'S OCCUPATION/DESIGNATION:GOVERNMENT
EMPLOYEE
DATE OF BIRTH 1993/07/07 DOMICILE: Kerala
GENDER Male MARITIAL STATUS:Unmarried
3. ADDRESS: CORRESPONDENCE ADDRESS PERMANENT ADDRESS
ADDRESS
ROSELAND PALLARIMANGALAM PO
MAVELIKARA
ROSELAND PALLARIMANGALAM PO
MAVELIKARA
DISTRICT ALAPPUZHA ALAPPUZHA
STATE Kerala Kerala
PINCODE 690107 690107
TELEPHONE 0479 - 2328081 0479 - 2328081
MOBILE 9061901919 --NA--
EMAIL 7sachin.77@gmail.com --NA--
4.EDUCATION PARTICULARS:
4(a).Qual/Stream/YOP: Final year B.Tech / Computer Science / 2015 Percentage 66.12%
Maximum Marks Marks Obtained Maximum Marks Marks Obtained
1st Semester 0 0 2nd Semester 1550 1082
3rd Semester 1100 750 4th Semester 1100 667
5th Semester 1100 708
5.NAME AND ADDRESS OF COLLEGE WHERE STUDIED : COLLEGE OF ENGINEERING CHENGANNUR College of
Engineering Chengannur Alappuzha District Kerala PIN 689121
6.NAME OF UNIVERSITY TO WHICH COLLEGE AFFILIATED AND ADDRESS: CUSAT
7. COLLEGE STATE:Kerala
8. I HAVE NOT ATTENDED ANY SSB TILL TO DATE WITH THE ARMY/NAVY OR THE AIR FORCE.
9.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.):NO APPLICABLE
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 paras 3 and 4 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: ..................................... October 2, 2014, 1:01 pm