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APPLICATION FO RM FO R SENIOR SECO NDARY RECRUIT SS R-02/2014 BATCH

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(UNMARRIED MALE CANDIDATES O NLY)FOR INDIAN NAVY O FFICE USE O NLY

CO DE NO . FO R O FFICE USE O NLY APPLICATIO N NO -S14217308136N

Valid Invalid

1. P ERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:-

NAME Shiwanshu Singh DATE OF BIRTH 1995/12/14

FATHER'S NAME Vidya Shankar Si ngh PERCENT AGE (10+2):- 76.2 %

2.NATIONALITY: INDIAN 3.MARITIAL STATUS: Unmarried 4.EMAIL:- singh.shiwanshukumar@gmail.com

5. ADDRESS: PERMANENT PRESENT

ADDRESSChief Proctor Office Vidya Shankar Singh BHUVaranasi

Chief Proctor Office Vidya Shankar Singh BHUVaranasi

DISTRICT Varanasi Varanasi

STATE Uttar Pradesh Uttar Pradesh

PINCODE 221005 221005

TELEPHONE

MOBILE 8896843003

6.EDUCATION PARTICULARS(HIGHLIGHTED SUBJECTS(10+2)):- Compulsory- Physics ,Maths Optional- Chemistry

Year of P assingAuthorityConducting Exam

State from which ExamPassed

Serial No. of MarksheetMarksobtained

Total marks Percentage

2013 CBSE Uttar Pradesh 0936502 381 500 76.2

7. NCC Certificat e NO8. HAVE YOU EVER BEEN ENROLLED IN ARMED FORCES BEFORE? NO9.HAVE YOU BEEN DISCHARGED FROM ARM ED FORCES BEFORE? NO10. VISIBLE IDENTIFICATION MARKS (AT LEAST TWO):-

(a)- Mole on right side of the cheek (b)- Mole near the right ear

DECLARATION

1. I hereby declare that all the stat ements made in the application are t rue to the best o f my kno wledge and belief and the application has been filled up by me.2. I have never been debarred from apperaing in any examination nor, have I ever been withdrawan from Defence T rainingEstablishments on disciplinary grounds, nor have I ever been arrested, prosecuted or con victed by criminal court or involved in any o ther case registered by the police. I have not submitted more than one application for this batch.3. I undertake no t t o make any claim for compensation if at any stage of selection, ineligibility fo r my candidature is detected and mycandidature is cancelled as a result thereof.4. Any wilful misrepresentat ion of fact s and concealment of informat ion will result in t he cancellation of t he candidature and may debar me permanently or for a specific period from applying for future examinations.

Place.................. Signature of parent Signature of Applicant

Date..................

IDENTIFICATIO N FO RM

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Name Shiwanshu Singh Application No. S14217308136N

Fathers name Vidya Shankar Si ngh Date of Birth 1995/12/14

Visible Identification Marks (at least two):- Signature of Applicant

(a)- Mole on right side of the cheek

(b)- Mole near the right ear

Note: Please forward complete printout of this application duly s igned to the address m entioned in t he advertisement along with the relevant documents as per advertisement.

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December 5, 2013, 8:05 pm