APPLICATIO N FO RM FO R Short Se rvice Commission - Unive rsity Entry Sche me (Engine e ring) Jun 14 BATCH (UNMARRIED MALE CANDIDATES

O NLY) FO R INDIAN NAVY O FFICE USE O NLY CO DE NO . VALIDITY STATUS APPLICATIO N NO -SUE143207991

Valid

Invalid

1. CHOICE OF ENT RY- [3] SSC(UES-NA) [1] SSC(UES-ENG) [2] SSC(UES-SUBMARINE ENGG) 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 GSHASHANK REDDY GGO VERDHAN REDDY 1993/04/17 Male NAT IONALIT Y: INDIAN FAT HER'S OCCUPAT ION/DESIGNAT ION:SRASSISTANT PHC DOMICILE: Andhra Prade sh MARIT IAL ST AT US:Unmarrie d PERMANENT ADDRESS FLAT NO 302 SHIVA SAI RESIDENCY MEERPETSARO O RNAGAR HYDERABAD Andhra Prade sh 500097 91 --NA---NA--

CORRESPONDENCE ADDRESS FLAT NO 302 SHIVA SAI RESIDENCY MEERPETSARO O RNAGAR HYDERABAD Andhra Prade sh 500097 91 9542355545 dilipshashank3@gmail.com

8.EDUCAT ION PART ICULARS: 8(a).Qual/Stream/YOP: Final ye ar B.Te ch / Ae ronautical Percentage 62.35% Engine e ring / 2014 Maximum Marks 1st Semester 3rd Semester 5th Semester 1000 750 750 Marks O btaine d 675 474 400 2nd Semester 4th Semester Maximum Marks 750 750 Marks O btaine d 525 420

9.NAME AND ADDRESS OF COLLEGE WHERE ST UDIED : Institute of ae ronautical e ngine e ring dundigal rangare ddy dist andhra prade sh 10.NAME OF UNIVERSIT Y T O WHICH COLLEGE AFFILIAT ED AND ADDRESS: JNTU HYDERABAD 11. COLLEGE ST AT E:Andhra Prade sh 12. DET AILS OF SSB INT ERVIEW(S) AT T ENDED: Se rvice Air Force Type O f Entry AFCAT Name O f SSB 2AFSB Mysore Month And Ye ar O f SSB AUG 2013 Batch No. Re c/ Not Re c

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.):NO 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. Place : ...................... Date: ? Signature (Director/ HOD): ..................................... ..................
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 ex amination. 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 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: .....................................

October 8, 2013, 10:29 pm