APPLICATION FORM FOR Short Service Commission Pilot JUN 17 BATCH

(UNMARRIED CANDIDATES ONLY)

FOR INDIAN NAVY OFFICE USE ONLY

Code No:

For Office use only:

Application No:
(Affix Photograph)

VALID / INVALID
SGP1721102316
1. CHOICE OF ENTRY : [1] SSC(PILOT)
2. PERSONAL PARTICULARS AS IN MATRICULATION CERTIFICATE:

NAME:

Nikunj
Kulwal

DATE OF BIRTH: 1995/08/05

FATHER'S NAME: Mr Praveen Kumar
FATHER'S OCCUPATION: Business
DOMICILE:

Delhi

3.NATIONALITY:

GENDER:

INDIAN

4.MARITIAL STATUS: Unmarried

6. ADDRESS:

Male

5.EMAIL: nkulwal@gmail.com

PERMANENT

PRESENT

B-3/12 Rajasthali Appartment

B-3/12 Rajasthali Appartment

Madhuban Chowk,Pitampura

Madhuban Chowk,Pitampura

DISTRICT

North Delhi

North Delhi

STATE

Delhi

Delhi

PINCODE

110034

110034

TELEPHONE --NA--

011-27012638

MOBILE

9910156906

--NA--

7. EDUCATION PARTICULARS:
Qualification

Stream

Year of Passing

Percentage

B.Tech

Information Technology

2017

63.86%

Appeared With Final Year Completed/Appearing With Appearing in Final Year - Appearing

Maximum Marks

Marks Obtained

Maximum Marks

Marks Obtained

1st Semester

1400

904

2nd Semester

1200

749

3rd Semester

1000

5th Semester

1200

595

4th Semester

1100

655

865

6th Semester

7th Semester

8th Semester

8. I HAVE NOT ATTENDED ANY SSB INTERVIEW TILL DATE

DECLARATION
1.I, hereby declare that I am unmarried, 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.
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.Tech as on date.

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
ONLY. You will be intimated via Email or SMS regarding your SSB Call-up, if shortlisted. Kindly check your Email inbox regularly.
Place ______________

Date _____________

September 15, 2016, 12:19 pm

Signature of Applicant