10/14/2016 UntitledDocument

APPLICATIONFORMFORPermanentCommissionUniversityEntryScheme(GSX)Jun
17BATCH
(UNMARRIEDMALE/FEMALECANDIDATESONLY)
FORINDIANNAVYOFFICEUSEONLY
CODE
VALIDITYSTATUS APPLICATIONNOPUX171206561
NO. Pleasepasteyourrecent
passportsizephotograph
here

Valid Invalid
UniqueNo:1712280052
1.CHOICEOFENTRY[1]PC{UESGS(X)}
2.PERSONALPARTICULARSASINMATRICULATIONCERTIFICATE:
NAME RAMNIKUJJWAL NATIONALITY:INDIAN
FATHER'SNAME UpendraKumar FATHER'SOCCUPATION/DESIGNATION:Doctor
DATEOFBIRTH 1994/12/13 DOMICILE:Delhi
GENDER Male MARITIALSTATUS:Unmarried

3.ADDRESS: CORRESPONDENCEADDRESS PERMANENTADDRESS

ADDRESS Flatno.574,FirstFloor,L.I.GFlats Flatno.102,RamKrishnaPlaza
DISTRICT NorthWestDelhi Patna
STATE Delhi Bihar
PINCODE 110040 800020
TELEPHONE
MOBILE 9711259853 NA
EMAIL ramnik.ujjwal@nitdelhi.ac.in NA
4.EDUCATIONPARTICULARS:
4(a).Qual/Stream/YOP:FinalyearB.Tech/Electrical/[NULL] AggregateGrade(range1to10):7.07
2017 Percentage67.13%
MaximumMarks MarksObtained MaximumMarks MarksObtained
1stSemester 100 66.88 2ndSemester 100 67.92
3rdSemester 100 65.17 4thSemester 100 68.78
5thSemester 100 66.88
5.NAMEANDADDRESSOFCOLLEGEWHERESTUDIED:NationalInstituteOfTechnologyDelhiIAMRCampus,A7,
Narela,Delhi40
6.NAMEOFUNIVERSITYTOWHICHCOLLEGEAFFILIATEDANDADDRESS:NationalInstituteOfTechnology
7.COLLEGESTATE:Delhi
8.IHAVENOTATTENDEDANYSSBTILLTODATEWITHTHEARMY/NAVYORTHEAIRFORCE.
9.Detailsofserviceundercentral/stateGovt.ifany(Candidatesalreadyinserviceshouldapplythroughproperchanneland
obtainNOCfromthepresentemployer.):NA

APPLICATIONFORMTOBESIGNEDBYTHEDIRECTOROFENGINEERINGCOLLEGE/HEADOF
DEPARTMENT
CertifiedthatMiss/Mr....................................................................................isstudyinginthisUniveristy/College/Institute
andthatdetailsfurnishedbyhiminparas3and4oftheapplicationformhavebeencheckedwithreferencetorelevantrecords
andfoundcorrect.
Place:......................Date:.................. Signature(Director/HOD):.....................................
DECLARATION
1.I,herebydeclarethatIamunmarriedmale/female,governedbynationalityconditionaslaiddownbytheGovernmentofIndiaand
haveneverbeendebarredfromappearingatanyexamination.Ihaveneverbeenarrested/prosecutedandconvictedbyacriminalcourt
orinvolvedinanyothercaseregisteredbythePolice.
2.I,hereby,solemnlydeclarethatallthestatementsmadeintheaboveapplicationaretrueandcorrecttothebestofmyknowledgeand
belief.
3.I,fullyunderstandthatintheeventofanyinformationbeingfoundfalseorincorrect,appropriateactioncanbetakenagainstme.
4.Eligibilitycriteriawillbeverifiedonreportingattheselectioncentres.Iffoundineligible,Iunderstandthatcriminalproceedingscan
beinitiatedagainstmeforfraudulententryandfalsificationofdocuments.IalsoacceptthatnoTA/DAwillbeadmissibletomein
suchcases.

Note:ThecopyoftheapplicationformistobesubmittedtotheCampusSelectionTeamofIndianNavyatthetimeofCampusInterview.The
dateandtimeofinterviewwillbeintimated.
Place:......................Date:.................. SignatureofApplicant:..................................... October14,2016,10:48pm

http://www.joinindiannavy.gov.in/th_officer_ues.php?applicationno=Quz53Ruz52yYv730A23MXQp690A23MM7A3l36P12T98OP7Yup6T98OP0A23M 1/1