11/23/2018 :: ONLINE APPLICATION ::

INDIAN COAST GUARD

ONLINE APPLICATION FORM
Application No. : 219/139032 Roll No. :
Affix recent
(1) Name of the post applied for : Asst. Commandant General Duty
passport size
(2) colour Photo
Centre at which you wish to appear for Test :
Date and Time of Reporting at Centre :

Centre
Priority Full Address of the Centre
Name
COAST GUARD SELECTION BOARD, A-1, SECTOR-24,
NOIDA
1 OPPOSITE ADOBE BUILDING, DISTRICT-GAUTAM BUDHA
- NO
NAGAR, NOIDA, UP – 201 301

(3) Name of the candidate (as in Matriculation) :

SIVAM KUMAR Gender : Male
(4) Current postal address :
31A 109 24F PHASE 3 JANGJEET NAGAR RAJPUR CHUNGI AGRA, CITY: AGRA, STATE:
UTTAR PRADESH, DISTRICT : AGRA, PIN : 282001
(5) Permanent address :
31A 109 24F PHASE 3 JANGJEET NAGAR RAJPUR CHUNGI AGRA, CITY: AGRA, STATE:
UTTAR PRADESH, DISTRICT : AGRA, PIN : 282001
(6) E-mail ID : sivamkumar0120@gmail.com Mobile No : +919808963163
(7) Mother's name : USHA DEVI
(8) Father's name : HARISHYAM
(9) Category : OBC (10) Date of Birth : 20 Aug 1997 (11) Nationality : Indian
(12) Qualification :
Compl. Compl. Year of
Qualification Board/Institution AggrPercent
Subject Mark Passing
12th CBSE 75 Physics 74 2015
Maths 67 2015
DR. B.R. AMBEDKAR
Graduation(B.A.) 61.31 --NA-- 0 2018
UNIVERSITY, AGRA
(13) Knowledge of Swimming : YES
(14) Proficiency in sports, National Level (attach photocopies of certificate) : NO
(15) NCC certificate obtained (attach photocopy of certificate, if yes) : GRADE-'A'
(16) Marital Status : Unmarried
(17) Is Wards of Coast Guard uniform personnel deceased while in service : NO
(18) Is your father serving /retired from Defence : YES - Army
(19) Is Service Personnel : NO
(20) Declaration :
I, hearby solemnly declare that all the statements made in the above application are true and correct to
the best of my knowledge and belief. I fully understand that in the event of any information being
found false or incorrect, appropriate action can be taken against me.
Place : AGRA Signature :
http://www.joinindiancoastguard.gov.in/Report.aspx?cxobg8IEqzOZgJyRlZ+0mAiQfReODys+l+bsWLkabK8= 1/2
11/23/2018 :: ONLINE APPLICATION ::

Date : 23/11/2018 Name of the Applicant : SIVAM

KUMAR
Print

http://www.joinindiancoastguard.gov.in/Report.aspx?cxobg8IEqzOZgJyRlZ+0mAiQfReODys+l+bsWLkabK8= 2/2