APPLICATION FORM FOR Short Service Commission Executive{GS(X)} JAN 16 BATCH

(UNMARRIED MALE CANDIDATES ONLY)

FOR INDIAN NAVY OFFICE USE ONLY

Code No:

For Office use only:

Application No:
(Affix Photograph)

VALID / INVALID
SGX1610801853
1. CHOICE OF ENTRY : [1] SSC{GS(X)}

[2] SSC{GS(Hydro)}

2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:

NAME:

madhan c

DATE OF BIRTH:

1991/12/24

FATHER'S NAME:

vs chinnusamy

FATHER'S OCCUPATION:

self employed

DOMICILE:

Tamilnadu

GENDER:

Male

BLOOD GROUP:

B- (B Negative)

NCC:

No

3.NATIONALITY:

INDIAN

6. ADDRESS:

4.MARITIAL STATUS: Unmarried

5.EMAIL: madhanvc8@gmail.com

PERMANENT

PRESENT

7 vatakal valasar streetvengiyampalayam

7 vatakal valasar streetvengiyampalayam

DISTRICT

erode

erode

STATE

Tamilnadu

Tamilnadu

PINCODE

638154

638154

TELEPHONE --NA--

91-99409539

MOBILE

9940953954

--NA--

7. EDUCATION PARTICULARS:
Qualification

Stream

Year of Passing

Percentage

B.E

Any Discipline

2013

71.5%

Maximum Marks

Marks Obtained

Maximum Marks

Marks Obtained

1st Semester

10

7.3

2nd Semester

10

7.1

3rd Semester

10

7.1

4th Semester

10

7.2

5th Semester

10

7.2

6th Semester

10

7.0

7th Semester

10

7.3

8th Semester

10

7.0

8. I HAVE NOT ATTENDED ANY SSB INTERVIEW TILL DATE

DECLARATION
1.I, hereby declare that I am unmarried, 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 GOI
documents. I also accept that no TA/DA will be admissible to me in such cases.
5. I have completed my B.E as on date.

NOTE:
Please forward the print out of this application duly signed to the address mentioned in the advertisement along with relevant documents by ORDINARY POST
ONLY. You will be intimated via Email or SMS regarding your SSB Call-up, if shortlisted. Kindly check your Email inbox regularly.
Place ______________

Date _____________

March 1, 2015, 3:53 pm

Signature of Applicant