APPLICATION FORM FOR MATRIC RECRUIT MR/NMR- 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
C15215066787N
1. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:
NAME:

SHAILENDRA

DATE OF BIRTH:

1997/09/30

FATHER'S NAME:

PREM PAL

PERCENTAGE :

89.3

2.NATIONALITY:

INDIAN

3.MARITIAL STATUS:

5. ADDRESS:

Unmarried

4.EMAIL: 30shailendra@gmail.com

PERMANENT

PRESENT

GALI N.5 NEAR BRIJWASI SCHOOL EKTA NAGAR PILIBHIT

GALI N.5 NEAR BRIJWASI SCHOOL EKTA NAGAR PILIBHIT

DISTRICT

PILIBHIT

PILIBHIT

STATE

Uttar Pradesh

Uttar Pradesh

PINCODE

262001

262001

--NA--

7351964188

TELEPHONE
MOBILE

6. EDUCATION PARTICULARS(HIGHLIGHTED SUBJECTS(10+2)):-Compulsory- and OptionalYear of Passing

Authority Conducting Exam

State from which Exam Passed

Serial No. of Certificate

Percentage

2012

CBSE

Uttar Pradesh

1167130

89.3

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) CUT MARK ON RIGHT HAND

NO
NO
NO

(b) MOLE ON CHEST

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

SHAILENDRA

Father's name PREM PAL

Visible Identification Marks (at least two):(a) CUT MARK ON RIGHT HAND
(a) MOLE ON CHEST

Application No. C15215066787N

Date of Birth

1997/09/30
(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.
December 22, 2014, 2:43 pm