APPLICATION FORM FOR SENIOR SECONDARY RECRUIT SSR-02/2015 BATCH

(UNMARRIED MALE CANDIDATES ONLY)

FOR INDIAN NAVY OFFICE USE ONLY

Code No:

For Office use only:

Application No:
(Affix Photograph)

VALID / INVALID
S15225040195N
1. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:
NAME:

shivanand dubey

DATE OF BIRTH:

1995/10/10

FATHER'S NAME:

shashikant

PERCENTAGE (10+2):

45.33

2.NATIONALITY:

INDIAN

5. ADDRESS:

3.MARITIAL STATUS:

Unmarried

4.EMAIL: dubeyshivanand9@gmail.com

PERMANENT

PRESENT

bk 404/room no-12 near post office o.t sec opp krishna cottage apt. ulhasnagar- 1

bk 404/room no-12 near post office o.t sec opp krishna cottage apt. ulhasnagar- 1

DISTRICT

thane

thane

STATE

Maharashtra

Maharashtra

PINCODE

421001

421001

TELEPHONE
MOBILE

9545798523

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

Year of Passing

Authority Conducting Exam

2014

STATE BOARD

State from which Exam Passed Serial No. of Certificate Marks obtained

Maharashtra

513535

7. NCC Certificate
8. HAVE YOU EVER BEEN ENROLLED IN ARMED FORCES BEFORE?
9. HAVE YOU BEEN DISCHARGED FROM ARMED FORCES BEFORE?
10. VISIBLE IDENTIFICATION MARKS (AT LEAST TWO):(a) blackhead just near down form forehead

272

Total marks

Percentage

600

45.33

NO
NO
NO

(b) blackhead in right hand at the musclearm

DECLARATION
1. I hereby declare that all the statements made in the application are true to the best of my knowledge and belief and the application has been filled
up by me.
2. I have never been debarred from appearing in any examination nor, have I ever been withdrawan from Defence Training Establishments on
disciplinary grounds, nor have I ever been arrested, prosecuted or convicted by criminal court or involved in any other case registered by the police. I
have not submitted more than one application for this batch.
3. I undertake not to make any claim for compensation if at any stage of selection, ineligibility for my candidature is detected and my candidature is
cancelled as a result thereof.
4. Any wilful misrepresentation of facts and concealment of information will result in the cancellation of the candidature and may debar me
permanently or for a specific period from applying for future examinations.

Place ___________
Date _____________

Signature of Parent

Signature of Applicant

IDENTIFICATION FORM
Name

shivanand dubey

Father's name shashikant

Visible Identification Marks (at least two):(a) blackhead just near down form forehead
(a) blackhead in right hand at the musclearm

Application No. S15225040195N

Date of Birth

1995/10/10
(Affix Photograph)
Signature of Applicant

NOTE:
Please forward the print out of this application duly signed to the address mentioned in the advertisement along with relevant documents by ordinary
post.
November 25, 2014, 6:32 pm