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APPLICATIO N FO RM FO R Short Se rvice Commission - Unive rsity Entry Sche me (O bse rve r) Jul 14 BATCH (UNMARRIED MALE/ FEMALE CANDIDATES O NLY) FO R INDIAN NAVY O FFICE USE O NLY CO DE NO . VALIDITY STATUS APPLICATIO N NO -SUO 133201241

Valid

Invalid

1. CHOICE OF ENT RY- [3] SSC(UES-ELE) [2] SSC(UES-PILOT ) [1] SSC(UES-OBSERVER) 2. PERSONAL PART ICULARS AS IN MAT RICULAT ION CERT IFICAT E:NAME FAT HER'S NAME DAT E OF BIRT H GENDER 7. ADDRESS: ADDRESS DIST RICT ST AT E PINCODE T ELEPHONE MOBILE EMAIL SRIRAMO JU VISHAL SRIRAMO JU CHANDRAMO HAN 27/07/1993 Male NAT IONALIT Y: INDIAN FAT HER'S OCCUPAT ION/DESIGNAT ION:AGRICULTURAL RETIRED EMPLO YEE DOMICILE: Andhra Prade sh MARIT IAL ST AT US:Unmarrie d PERMANENT ADDRESS H.NO 8-3-404 SAPTHAGIRI CO LO NY KARIMNAGAR KARIMNAGAR Andhra Prade sh 505001 --NA---NA--

CORRESPONDENCE ADDRESS H.NO 8-3-404 SAPTHAGIRI CO LO NY KARIMNAGAR KARIMNAGAR Andhra Prade sh 505001 9030260130 vishvishal49@gmail.com

8.EDUCAT ION PART ICULARS: 8(a).Qual/Stream/YOP: Pre Final Ye ar B.Te ch / Ele ctronics & Communication / 2014 Maximum Marks 1st Semester 3rd Semester 5th Semester 1000 725 0 Marks O btaine d 774 558 0

Percentage 77.54% Maximum Marks 2nd Semester 4th Semester 750 0 Marks O btaine d 587 0

9.NAME AND ADDRESS OF COLLEGE WHERE ST UDIED : JYO THISHMATHI INSTITUTE O F TECHNO LO GICAL SCIENCES RAMAKRISHNA CO LO NY 10.NAME OF UNIVERSIT Y T O WHICH COLLEGE AFFILIAT ED AND ADDRESS: JNTU HYDERABAD 11. COLLEGE ST AT E:Andhra Prade sh 12. I HAVE NOT AT T ENDED ANY SSB T ILL T O DAT E WIT H T HE ARMY/NAVY OR T HE AIR FORCE. 13.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.):NA 14.APPLICATIO N FO RM TO BE SIGNED BY THE DIRECTO R O F ENGINEERING CO LLEGE/HEAD O F DEPARTMENT Certified that Miss/Mr.....................is studying in this Univeristy/ College/Institute and that details furnished by him in para 7 and 8 of the application form have been checked with reference to relevant records and found correct. Signature (Director/ HOD): Place : ...................... Date: .................. .....................................
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.
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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: .....................................

July 10, 2012, 8:45 pm

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