APPLICATION FOR GRANT OF Affix your self-attested

SHORT SERVICE COMMISSION IN THE passport size recent colour

INDIAN NAVY UNDER TECHNICAL BRANCHES photograph (Don’t staple)
JAN 2012 COURSE

Regd. No……………………….. (For Official Use Only)

1. Applying for Branch/Cadre 1 _________________________

2. Name in Block Capitals as in Matriculation Certificate

3. Expanded Name if abbreviated in Sl 2 Above: (abbreviated part only):

4. Father’s Name

5. Father’s Occupation/ Designation:

6. Date of Birth (DD/ MM/ YYYY):

- -

7. Stream of BE / BTech …………………………………………………

8. Total Marks of BE/ B.Tech (Total of 1st to 8th Semester)
Marks Obtained Total marks Aggregate % of Marks

9. Details of Marks secured in Graduation (BE/ B.Tech)above:

Name & Name & Semester/ Year wise Marks secured
Address Address Semester/ Maximum marks Marks Obtained % of Marks
of of Year
College/ University
Institute

II
III
IV
V
VI
VII
VIII

10. Correspondence Address:

PIN Mobil Tele
No
Email

11. Permanent Address:

PIN

12. Nationality

13. State:

14. Marital Status: Married Unmarried

15. Priority Cadre:Technical(General Service: Male Sub Marine Cadre

Female

16. Ievel of Participation/achievement in sports,NCC extra circular activities:

………………………………………………………………………………………..

17. 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)
18. Have you attended any SSB interview earlier (If yes, give details of all earlier attempts)

Source of Entry Navy Army Air Force

SI
No
(a) Type of Entry
(b) Name and Station of SSB
(c) Batch No.
(d) Month and Year of Interview
(e) Rec/Not Rec

DECLARATION

19. I, hereby, declare that I am unmarried male/ female candidate, 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.h
20. 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.
21. I fully understand that in the event of any information being found false or incorrect,
action can be taken against me.
Place: Signature:…………………
Date: Name of the Applicant:……………………….