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  Personal Information

Note/Instruction:
1. Name (Applicant name, father’s name, mother’s name) in this application and all documents like
matriculation certificate, category certificate (SC/ST/OBC/EWS), Id card, educational certificates should be
same or else the candidature will be cancelled.
2. Please do not use any prefix such as Mr. or Ms.
3. The Email id of profile cannot be changed further so please use working email id.
4. Id provided here will have to be presented in all stages of examination.
5. Birthmark, Mole, Burn/Injury mark to be entered as identification mark by the candidate.
6. The candidates are to scan the original documents (neither photocopy nor self-attested photocopy is to be
scanned) as applicable for the post applied and upload in the online application. Applications with blurred
photograph, signature, uploaded documents and uploaded thumb impression will be rejected during
document verification at Stage-I, II and III and result in cancellation of candidature. If the proper photograph
is not uploaded by a candidate, his candidature will be cancelled. Specimen of photographs available on
website.
7. All Documents uploaded must be in Hindi or English. Candidate to upload both original and English
translation of document as one file/document (after merging both documents) if the document is in any
language other than English or Hindi.
8. All document files must be in .jpeg/ .jpg/ .png format and file size should be between 10KB to 100KB.
9. Candidates to upload class 10th passing certificate with date of birth mentioned on certificate. If date of birth
is not mentioned in 10th passing certificate, then Birth certificate to be uploaded (Original certificate be
produced in all stages of recruitment).
10. Candidates belonging to OBC but coming in the 'Creamy Layer' are to apply as Unreserved Candidate.
11. If validity is mentioned on category certificate then enter the validity date as per category certificate.
12. If no validity date is mentioned on category certificate then the certificate is considered lifelong valid,
however, the candidate to enter validity date upto 31 Aug 2023 (as per ICG advertisement).
13. Any discrepancy or anomaly in clarity of images of uploaded documents in the online application will lead
to cancellation of candidature.
14. Click here for various examples of document verification for all posts. The documents will be verified by ICG
as per the examples mentioned during all stages of CGEPT examination.

NAME Piyush Kumar FATHER'S Shiv Shankar MOTHER'S Lalti Devi

NAME NAME
Kumar
EMAIL ID sawanforu822@gmail. MOBILE 919525226408 NATIONALI Indian
TY
com
MARITAL Unmarried GENDER Male AADHAR XXXXXXXX9149
STATUS
NUMBER

ID CARD Aadhaar Card ID CARD XXXXXXXX9149 IDENTIFICA Burn Mark On Right

NUMBER TION MARK
1
Leg

IDENTIFICA Cut Mark On Left CATEGORY Other DATE OF 05-Jun-2022

TION MARK ISSUE OF
2
Hand Backward CATEGORY
Class (OBC) CERTIFICAT
(Non-creamy) E

CATEGORY Always Valid DATE OF 02-May-2001 DATE OF 10th Class

CERTIFICAT BIRTH BIRTH
E VALID PROOF
Marksheet/Cer
UPTO TYPE tificate

AGE No FEE No EMPLOYME Unemployed

RELAXATIO WAVIER NT TYPE
N CLAIMED

COMMUNIT Always valid

Y
CERTIFICAT
(no validity date
E VALIDITY mentioned on
certificate)

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ID Proof (Aadhaar Card) Date of Birth Proof (10th Class

Marksheet/Certificate)

  Post Selection

POST Navik(GD)
APPLIE
D

  Class 10th Details

Note/Instruction:
1. 10th marksheet and certificate need to be uploaded at Stage-II.
2. In case of CGPA or Grade, conversion formula document need to be uploaded at Stage-II.
3. In case of two or more candidates scores same marks in Stage-I, then ICG will be calculating the
percentage of the candidates as per the tie breaking rule mentioned in CGEPT advertisement.

EDUCATIO Central Board GRADING CGPA DO YOU No

N BOARD SYSTEM AS HAVE
of Secondary INDICATED ADDITIONA
Education IN L
MARKSHEE MARKSHEE
T T

10TH 1384746 YEAR OF 2017

CERTIFICAT PASSING
E NUMBER

Subject English Hindi Mathematics Science Social Sciences

CGPA
7 7 7 7 7
Obtained

Out of
10 10 10 10 10
CGPA

  Class 12th Details

Note/Instruction:
1. 12th marksheet and certificate need to be uploaded at Stage-II.
2. In case of CGPA or Grade, conversion formula document need to be uploaded at Stage-II.
3. In case of two or more candidates scores same marks in Stage-I, then ICG will be calculating the
percentage of the candidates as per the tie breaking rule mentioned in CGEPT advertisement.

EDUCATIO Bihar School GRADING Percentage DO YOU No

N BOARD SYSTEM HAVE
Examination INDICATED ADDITIONA
Board IN L
MARKSHEE MARKSHEE
T T

0065607 2019
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12TH YEAR OF
CERTIFICAT PASSING
E NUMBER

Subject Physics Mathematics Chemistry

Marks
68 64 77
Obtained

Total
100 100 100
Marks

  Additional Details

Note/Instruction:
1. You have to clear swimming test as per prescribed norm, if inducted in service. You are liable to discharged
from service, if you fail to clear the swimming test.

1) WHETHER HAVING NCC 'A/B/C' CERTIFICATE : No

2) WHETHER STUDIED IN SAINIK SCHOOL: No

3) WHETHER SERVING IN ARMED FORCES No

4) HAVE YOU REPRESENTED AT ANY LEVEL IN SPORTS? No

5) DO YOU KNOW SWIMMING? No

6) ARE YOU SON OF A SERVING / RETIRED / DISCHARGED DECEASED COAST GUARD No
PERSONNEL (OFFICER / SO / EP / CIVILIAN STAFF)
7) ARE YOU SON OF A COAST GUARD PERSONNEL WHOSE DEATH IS ATTRIBUTABLE TO No
SERVICE?
8) ARE YOU SON OF A COAST GUARD PERSONNEL WHOSE DEATH IS NOT ATTRIBUTABLE TO No
SERVICE?

9) ARE YOU CHILD OF WAR WIDOW OF (ARMY/NAVY/AIR FORCE)? No

10) ARE YOUR PARENTS (FATHER / MOTHER) SERVING / RETIRED FROM DEFENCE FORCES? No

11) WHETHER YOU ARE EMPLOYED IN CENTRAL / STATE GOVT. / PUBLIC SECTOR No
12) HAVE YOU BEEN DISCHARGED FROM THE INDIAN ARMY / INDIAN NAVY / INDIAN AIR FORCE No
OR ANY GOVERNMENT ORGANIZATION ?
13) HAS ANY WARRANT OR SUMMONS FOR YOUR APPEARANCE AS WITNESS BEEN ISSUED AND No
PENDING BEFORE A COURT OF LAW FOR THE TIME BEING IN FORCE ?
14) ARE ANY PROCEEDINGS IN RESPECT OF AN OFFENCE ALLEGED TO HAVE BEEN COMMITTED No
BY YOU PENDING BEFORE A CRIMINAL COURT IN INDIA ?
15) HAS ANY WARRANT OR SUMMONS FOR YOUR OFFENCE BEEN ISSUED AND PENDING No
BEFORE A COURT OF LAW FOR THE TIME BEING IN FORCE ?
16) HAS A WARRANT FOR YOUR ARREST BEEN ISSUED BY A COURT UNDER ANY LAW FOR THE No
TIME BEING IN FORCE ?
17) HAVE YOU, AT ANY TIME PRECEDING THE DATE OF THIS APPLICATION, BEEN CONVICTED BY No
A COURT OF INDIA FOR ANY OFFENCE AND SENTENCED IN RESPECT THEREOF TO
IMPRISONMENT ?
18) HAVE YOU APPLIED IN HIGHER COURT FOR ACQUITTAL AGAINST THE CONVICTION OF No
LOWER COURT?
19) HAVE YOU EVER BEEN DEBARRED BY ICG / ARMY / NAVY / AIR FORCE / UPSC / CENTRAL No
OR STATE GOVT. DURING ANY RECRUITMENT PROCESS ?

  Communication Details

Note/Instruction:

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1. In case of reserved category applicants, either current or permanent address of online application should
be same as the address mentioned in caste/category certificate (SC, ST, OBC(Non-Creamy Layer) & EWS).
Permanent Address
HOUSE/ST village datiyana LANDMARK jagdamba mandir POST datiyana
REET OFFICE

COUNTRY India STATE/ UT BIHAR DISTRICT PATNA

SUB Paliganj PIN CODE 801104 PHONE NO N.A
DISTRICT WITH AREA
CODE

Present/Current Address
HOUSE/ST 4m/135 bh colony LANDMARK Union bank of India POST bahadurpur
REET OFFICE
bhoothnath road
COUNTRY India STATE/ UT BIHAR DISTRICT PATNA
SUB Patna Rural PIN CODE 800026 PHONE NO N.A
DISTRICT WITH AREA
CODE

Domicile Details
DOMICILE Bihar
STATE

  Photo and Signature

Note/Instruction:
1. Passport size recent colour photograph (should not be older than three months prior to the date of
opening of application) (front portrait in light background without head gear (except for Sikhs).
2. The photograph should be without cap, spectacles and both ears should be visible.
3. The photographs is to be taken with candidate holding a black slate in front of his chest with his name and
date of photograph taken, clearly written on it with white chalk in capital letters.
4. File must be in .jpeg / .jpg / .png format and file size should be between 10KB to 100KB.
5. Any discrepancy or anomaly in clarity of images of uploaded documents in the online application will lead
to cancellation of candidature.

PHOTO LEFT HAND THUMB IMPRESSION IMAGE SIGNATURE

  Stage - I - Exam City Preferences

Note/Instruction:
1. Candidates are to fill first choice within 30 kms from the present residence. In case if no centre is available
within 30 kms then the other choices should be nearest to the present address.
2. Your next 4 preferences nearest to present address in increasing order of distance.
3. Non-compliance to these instructions may lead to cancellation of your candidature during document
verification.

1. Patna 2. Chapra 3. Bhagalpur 4. Gaya 5. Muzaffarpur

  Stage - II - Exam City Preferences

1. Kolkata 2. 3. Noida 4. Kochi 5. Gandhinagar

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Bhubaneshwar

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  Uploaded Documents

ID PROOF (AADHAAR CARD)

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DATE OF BIRTH PROOF (10TH CLASS

MARKSHEET/CERTIFICATE)

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COMMON REASONS FOR REJECTION DURING

DOCUMENT VERIFICATION

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COMMON REASONS FOR REJECTION DURING

DOCUMENT VERIFICATION

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COMMON REASONS FOR REJECTION DURING

DOCUMENT VERIFICATION

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
CI Patna DA 20-09-2022
TY TE
* *

I hereby declare that all the above information provided by me is correct.

I owe allegiance to the sovereignty, unity and integrity of India. I have not lost, surrendered or been
deprived of the citizenship of India.
I affirm that the information and particulars given by me in this form are true and correct. I further state
that I am not suppressing any material information in this regard. I further affirm that the certificates
(DOB, Matriculation, 10th marks sheet, Cast Certificate, ID proof) of documentary proof uploaded in
support of my application for recruitment of Navik (GD)/ Navik (DB)/ Yantrik (Mechanical)/ Yantrik
(Electrical)/ Yantrik (Electronics / Telecommunication (Radio/ Power)) are authentic and solely pertain
to me and I am fully responsible for the accuracy of the same. I am liable to be penalized or
prosecuted and my candidature will be cancelled if found otherwise. I am also aware that my
candidature will be cancelled, if the documents are not found genuine by the issuing authority during
subsequent verification by Indian Coast Guard even if I clear computer based written examination, PFT,
document verification and Medical conducted at Stage-I/ Stage-II / Stage-III and inducted into
service.
I have read the complete advertisement for the said post of Navik (GD)/ Navik(DB)/
Yantrik(Mechanical)/ Yantrik(Electrical)/ Yantrik(Electronics / Telecommunication (Radio/ Power)) of
Coast Guard website and I am eligible to apply. I have also read the FAQ section on Coast Guard
Website before filling the online application.
I understand that Indian Coast Guard reserves the right to conduct re-assessment of candidates at
Stage II and also at any stage of the recruitment process prior issue of appointment letter to avoid
impersonation. I understand that my candidature can be cancelled on account of impersonation and
the decision of Indian Coast Guard will be final and binding on me in this regard.
I have also understood and read the remarks on Coast Guard Website regarding common observation
for cancelling the candidature during document verification. I certify that all my documents meet the
criteria as mentioned on Coast Guard Website.
I understand that Coast Guard will be communicating the result of Stage-I, Stage-II and Stage-III on
the Coast Guard Website and my login dashboard. I will not claim for re-examination if I fail to see the
requisite communication on Coast Guard Website and my login dashboard.
I understand that Biometric impression is mandatory for appearing in the Stage-I, Stage-II and Stage-
III. Only left thumb biometric will be captured during Stage-I of examination. The biometric during
subsequent stages is to match with the biometric of Stage-I. In case the biometric of left thumb is not
captured then the biometric of right thumb will be captured and will be used for subsequent
verification. Apart from left and right thumb, no other finger will be considered for the biometric. If I am
not able to establish biometric with left or right thumb impression, then I shall not be allowed to
appear for the examination and my candidature will be cancelled. It is my responsibility to check
beforehand that the biometric machines are able to capture the fingerprint image. In case, if the
biometric machine is not able to capture the fingerprint image due to Mehndi, wax, etc then, I will not
be allowed to appear in the examination. I will make no further claim in this regard as biometric
fingerprinting is one of the most important access control security system implemented in Indian Coast
Guard and cannot be waived off under any circumstances to rule out impersonation. I understand that
if I am not allowed by Coast Guard for appearing in Stage-I/ Stage-II / Stage-III owing to non-capture
of Biometric due to mehndi, wax, etc. then the application fees will not be refunded under any
circumstances.
NO CLAIM / RISK UNDERTAKING I am a candidate for recruitment in Indian Coast Guard. I give my full
and free consent at my own risk and that I shall not be entitled to claim any compensation or other
relief from the government in respect of any injury or disability which I may sustain in the course of or
as the result of any of the tests (both physical fitness test and medical test) administrated to me or
attended by me during the recruitment procedure, whether due to my own negligence or any other
person or otherwise.
I understand that my candidature will be cancelled and I will be debarred from future Coast Guard
Recruitment examinations in case I am found to be involved in malpractice during process computer
based written examination, PFT, document verification and Medical conducted at Stage-I/ Stage-II /
Stage-III of the current recruitment process.

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I understand that I can apply for only one post in one recruitment cycle i.e. Navik (GD) or Navik (DB) or
Yantrik (Electrical) or Yantrik (Mechanical) or Yantrik (Electronics / Telecommunication (Radio/ Power). I
have not submitted multiple applications in one recruitment cycle. In case if multiple applications are
detected by ICG then all my applications will be rejected and the application fees for all the submitted
application forms will not be refunded by ICG.
I understand that I have to upload the correct document as directed in the online application form.
Non-upload/ wrong upload/ interchanged upload of the document in online application will lead to
cancellation of candidature.
I understand that non-upload/wrong upload/interchanged upload of the additional documents prior
Stage-II will also lead to cancellation of candidature during document verification at Stage-II, Stage-III
and Stage-IV.
I declare to remember my mobile number and e-mail id entered during filling of the online application
as the correspondence will be through e-mail id only. Post submitting the application, I will see the e-
mail id and mobile number only in encrypted form. No request for retrieving the e-mail or mobile
number will be entertained.
I understand that uploading of documents/additional documents is restricted upto downloading of E-
admit card for Stage-II. No documents can be uploaded by me after downloading Stage-II E-admit
card. Failure of uploading of documents within the time promulgated by ICG will lead to the
cancellation of my candidature. Any request for uploading new document after downloading of E-
admit card for Stage-II will not be entertained.
I declare to visit ICG website and candidate’s dashboard on a daily basis to see various announcements
on ICG website. Failure to comply with instructions on ICG website will result in non-compliance of the
recruitment process and lead to cancellation of candidature. The notification for downloading E-admit
card for Stage-I, Stage-II & Stage-III and the result of various stages will be announced/published on
ICG website through my login dashboard and I will daily visit the website and comply with all
instructions. ICG will not be responsible if I fail to visit ICG website on a daily basis and comply with the
instructions therein given from time to time. The primary mode of communication with me will be
through ICG website or E-mail.
I declare that uploaded SC/ST/OBC (non-creamy layer)/EWS certificate comply with the instructions
given in the advertisement regarding the format of certificate for appointment to the post under
Government of India. If my candidature is cancelled on account of incorrect category document then I
shall not be considered against unreserved vacancy as I have submitted false information.
I understand that any false or incorrect information in the online application not duly supported with
the uploaded documents will lead to cancellation of candidature.
I understand that any false or incorrect information in the online application will lead to cancellation of
candidature.
I certify that I am in possession of originals of all the documents uploaded in the online application.
I understand that I will not lose the original documents due to either theft or negligence as uploaded
in online application. Failure to present the original document as uploaded in online application on
account of loss of documents will lead to cancellation of candidature. I understand that no request in
this regard will be entertained by ICG even if I produce an F.I.R. w.r.t. theft of my documents and my
candidature will stand cancelled.
I have completely checked the print preview of the application and I certify that my application is
correct in all aspects as per the advertisement. I have gone through the common reasons for rejection
as published on the website and I certify that my application is correct and does not fall for rejection in
document verification as per the rules prescribed in the advertisement for Stage-I, II & III as published
on the website.

Print Preview

 Checking for print preview

Note/Instruction:
1. You are directed to completely check the print preview of the application and certify that your
application is correct in all aspects as per the advertisement. You are directed to go through the
common reasons for rejection as published on the website and certify that your application is correct
and does not fall for rejection in document verification as per the rules prescribed in the
advertisement for Stage-I, II & III as published on the website. You may edit the application and the
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uploaded documents if there is any mistake or error before submitting the application. Once the
application is submitted, no changes are allowed.
HAVE YOU SEEN THE PRINT PREVIEW BEFORE SUBMITTING THE APPLICATION ? YES NO

DO YOU WANT TO EDIT THE APPLICATION OR THE UPLOADED DOCUMENTS IF THE DETAILS IN
YES NO
YOUR APPLICATION ARE INCORRECT OR THE DOCUMENTS ARE INCORRECTLY UPLOADED ?

DID YOU UTILIZE THE "EDIT" OPTION AFTER SEEING THE PRINT PREVIEW PRIOR FINAL
YES NO
SUBMISSION ?

DO YOU WANT TO SUBMIT THE APPLICATION FINALLY ?

YES NO
IF YOU CHECK YES, YOU WILL BE DIRECTED TO PAYMENT PAGE AND YOUR APPLICATION WILL BE
SUBMITTED AND NO CHANGES WILL BE ALLOWED FURTHER.

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