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APPLICATIO N FO RM FO R SENIO R SECO NDARY RECRUIT SSR-02/2014 BATCH (UNMARRIED MALE CANDIDATES O NLY) FO R INDIAN NAVY O FFICE USE O NLY CO DE NO . FO R O FFICE USE O NLY Valid Invalid APPLICATIO N NO -S14217308136N Paste your recent colour photograph (Do not staple)

1. PERSONAL PART ICULARS AS IN MAT RICULAT ION CERT IFICAT E:NAME FAT HER'S NAME Shiwanshu Singh Vidya Shankar Singh 3.MARIT IAL ST AT US: Unmarrie d
PERMANENT Chief Proctor Office Vidya Shankar Singh BHU Varanasi Varanasi Uttar Pradesh 221005

DAT E OF BIRT H PERCENT AGE (10+2):-

1995/12/14 76.2 %

2.NAT IONALIT Y: INDIAN

5. ADDRESS: ADDRESS DISTRICT STATE PINCODE TELEPHONE MOBILE

4.EMAIL:- singh.shiwanshukumar@gmail.com
PRESENT Chief Proctor Office Vidya Shankar Singh BHU Varanasi Varanasi Uttar Pradesh 221005 8896843003

6.EDUCAT ION PART ICULARS(HIGHLIGHT ED SUBJECT S(10+2)):- Compulsory- Physics ,Maths Optional- Che mistry Year of Passing 2013 Authority State from which Exam Conducting Exam Passed CBSE Uttar Prade sh Serial No. of Marksheet 0936502 Marks obtained 381 T otal marks Percentage 500 NO NO NO 76.2

7. NCC Certificate 8. HAVE YOU EVER BEEN ENROLLED IN ARMED FORCES BEFORE?

9.HAVE YOU BEEN DISCHARGED FROM ARM ED FORCES BEFORE?

10. VISIBLE IDENT IFICAT ION MARKS (AT LEAST T WO):(a)- Mole on right side of the che e k (b)- Mole ne ar the right e ar

DECLARATIO N 1. I hereby declare that all the statements made in the application are true to the best of my knowledge and belief and the application has been filled up by me. 2. I have never been debarred from apperaing in any examination nor, have I ever been withdrawan from Defence T raining Establishments on disciplinary grounds, nor have I ever been arrested, prosecuted or convicted by criminal court or involved in any other case registered by the police. I have not submitted more than one application for this batch. 3. I undertake not to make any claim for compensation if at any stage of selection, ineligibility for my candidature is detected and my candidature is cancelled as a result thereof. 4. Any wilful misrepresentation of facts and concealment of information will result in the cancellation of the candidature and may debar me permanently or for a specific period from applying for future examinations. Place.................. Date.................. Signature of parent Signature of Applicant

IDENTIFICATIO N FO RM Name Fathers name Shiwanshu Singh Vidya Shankar Singh Application No. Date of Birth S14217308136N 1995/12/14 Signature of Applicant Affix a latest passport size photograph

Visible Identification Marks (at least two):(a)- Mole on right side of the che e k (b)- Mole ne ar the right e ar

Note : Please forward complete printout of this application duly signed to the address mentioned in the advertisement along with the relevant documents as
per advertisement.
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