INDIAN COAST GUARD

ONLINE APPLICATION FORM

Application No. : 320/583477   Roll No. :  
(1) Name of the post applied for : Domestic Branch Affix recent
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
INDIAN COAST GUARD, DIRECTORATE OF
 
NOIDA RECRUITMENT, C-1, NEAR INDUS VALLEY PUBLIC
1
- NO SCHOOL, SECTOR-62, NOIDA, UTTAR PRADESH, PIN-
201301

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

  SANDEEP KUMAR MAURYA  Gender : Male
(4) Current postal address :
JAGDISH PUR POST MIRZAPUR AIHARI, CITY: UNCHAHAR, STATE: UTTAR
 
PRADESH, DISTRICT : RAEBARELI, PIN : 229401
(5) Permanent address :
JAGDISH PUR POST MIRZAPUR AIHARI, CITY: UNCHAHAR, STATE: UTTAR
 
PRADESH, DISTRICT : RAEBARELI, PIN : 229401
(6) E-mail ID :    sa***.com      Mobile No :    +9*****601
(7) Mother's name : LALLI DEVI
(8) Father's name : SADASHIV MAURYA
(9) Category : OBC  (10) Date of Birth : 06 Aug 1999   (11) Nationality : Indian
(12) Qualification :
Compl. Compl. Year of
Qualification Board/Institution AggrPercent
Subject Mark Passing
U.P. BOARD OF
HIGH SCHOOL &
10th 73.5 --NA-- 0 2014
INTERMEDIATE
 
EDUCATION
U.P. BOARD OF
HIGH SCHOOL &
12th 54.6 --NA-- 0 2016
INTERMEDIATE
EDUCATION
(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) : --NA--
(16) Marital Status : Unmarried
(17) Is Wards of Coast Guard deceased/Service Personnel : NO
(18) Is your father serving /retired from Defence : NO
(19) Is Service Personnel : NO
(20) Is EWS(Economically Weeker Sections) : NO
(21) 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 : KANPUR Signature :
Name of the Applicant :
Date : 01/11/2019
SANDEEP KUMAR MAURYA
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