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APPLICATION FORM FOR Short Service Commission Executive{GS(X)} Dec 12 BATCH (UNMARRIED MALE CANDIDATES ONLY) FOR INDIAN NAVY OFFICE USE ONLY CODE NO. VALIDITY STATUS APPLICATION NO-SGX1220805436

Valid Invalid 1. CHOICE OF ENTRY- [2] SSC(HYDRO) [1] SSC{GS(X)} 2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:NAME FATHER'S NAME DATE OF BIRTH GENDER SANCHAY GUPTA Mr Arvind Gupta 1989-10-28 Male

3.FATHER'S OCCUPATION/DESIGNATION:Service 4.NATIONALITY: INDIAN 7. ADDRESS: . ADDRESS DISTRICT STATE PINCODE TELEPHONE MOBILE EMAIL 5.DOMICILE: Madhya Pradesh 6.MARITIAL STATUS:Unmarried PERMANENT ADDRESS 122/7 Nanda Nagar Indore Madhya Pradesh 452011 997738 - 9629 --NA---NA-8(b).STREAM: IT 8(d).PERCENTAGE: 67.00% Marks Obtained 599 638 706 703 2nd Semester 4th Semester 6th Semester 8th Semester Maximum Marks 1000 1000 1000 1000 Marks Obtained 622 651 677 764

CORRESPONDENCE ADDRESS 122/7 Nanda Nagar Indore Madhya Pradesh 452011 997738 - 9629 9977389629 kishigupta@ymail.com

8.EDUCATION PARTICULARS: 8(a).QUALIFICATION: B.E 8(c).YEAR OF EXAM PASSED: 2011 Maximum Marks 1st Semester 3rd Semester 5th Semester 7th Semester 1000 1000 1000 1000

9.NAME AND ADDRESS OF COLLEGE WHERE STUDIED :Malwa Institute of Technology indore 10.NAME OF UNIVERSITY TO WHICH COLLEGE AFFILIATED AND ADDRESS:RGPV bhopal 11. I HAVE NOT ATTENDED ANY SSB TILL TO DATE WITH THE ARMY/NAVY OR THE AIR FORCE. 12.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.):None
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. 3. I, fully understand that in the event of any information being found false or incorrect, appropriate action can be taken against me.

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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.E as on date.

Place : .............................. Signature: .............................................. Date : ............................... Name of Applicant: ..............................

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