APPLICATION FORM FOR Short Service Commission - Engineering JUN 17 BATCH

(UNMARRIED MALE/ FEMALE CANDIDATES ONLY)

FOR INDIAN NAVY OFFICE USE ONLY
Code No: For Office use only: Application No:
(Affix Photograph)
VALID / INVALID
SGE1720904005
1. CHOICE OF ENTRY :
[1] GS(ENGINEERING) [2] SSC(SUB-Engg) [3] SSC{GS(Hydro)} [5] SSC(NA) [4] SSC{GS(X)}

2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:

NAME: MERAJUDDIN
ANSARI
DATE OF BIRTH: 1994/10/18
FATHER'S NAME: SAMSUDDIN ANSARI
FATHER'S OCCUPATION: RETIRED
DOMICILE: Bihar GENDER: Male
BLOOD GROUP: NCC: No

3.NATIONALITY: INDIAN 4.MARITIAL STATUS: Unmarried 5.EMAIL: ansari.merajuddin94@gmail.com

6. ADDRESS: PERMANENT PRESENT
AT-SURDA , SDF/2 P.O-SURDA MINES

AT-SURDA , SDF/2 P.O-SURDA MINES

DISTRICT EAST SINGHBHUM EAST SINGHBHUM

STATE Jharkhand Jharkhand

PINCODE 832303 832303
TELEPHONE --NA-- -
MOBILE --NA-- 7097975902
7. EDUCATION PARTICULARS:

Qualification Stream Year of Passing Percentage

B.Tech Mechanical 2015 82.38%
Maximum Marks Marks Obtained Maximum Marks Marks Obtained
1st Semester 100 79.42 2nd Semester 100 78.75
3rd Semester 100 77.80 4th Semester 100 85.88
5th Semester 100 79.61 6th Semester 100 80.75
7th Semester 100 87.02 8th Semester 100 89.77
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.Tech 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 _____________ August 26, 2016, 1:01 am

Signature of Applicant