APPLICATION FOR ADMISSION

GMDSS – INDIAN / GMDSS – UK

Application Number
1. :
(for Office use)
2. Preferred Course* : GMDSS – INDIAN

3. Required Course Dates* : 3rd april 2023

Name of the Candidate
4. (AS PER SSLC : PANDIYARAJAN M
CERTIFICATE/NCV)*
5. Father’s Name* : MARIYAPPAN

6. Date of Birth* : 05/09/1998

7. Place of Birth : NACHANDHUPATTI

2/35, VELLAR STREET, KULATHUR PO&TK,

PUDUKKOTTAI, TAMIL NADU-622504
8. Permanent Address* :

2/35, VELLAR STREET, KULATHUR PO&TK,

PUDUKKOTTAI, TAMIL NADU-622504
9. Present Address :

10. Nationality : INDIAN

11. Mobile Number* : 8220583851

Pandiyarajanmari98@gmail.com
12. Email ID* :

13. Qualification* : Bsc nautical science

SSLC Passed Cert No /
14. : Sslc cert no: 4244080
NCV Cert No.*
15. Aadhaar Number : 381684611915

16. Passport Number : S2807430

 17. CDC Number : MUM 367233

18. INDOS Number : 17NL0105

19. Hostel Requirement : Required

20. Height (in Cms) : 178

21. Color of Eyes : BLACK

22. Color of Hair : BLACK

23. Complexion :

24. Identification Mark : MOLE ON LEFT HAND

* - Mandatory

Payment Details (to be filled by Applicant)

Payment Mode BANK TRANSFER
DD/Bank Transfer/Card
DD/ UTR/IMPS Ref. Number# 301414552366
Bank STATE BANK OF INDIA
Transfer Date 14/01/2023
Transfer Amount 10000/-
Transferred to AMET Bank Name INDIAN OVERSEAS BANK
Remitter’s Name PANDIYARAJAN
# - For NEFT/RTGS Transfer quote UTR Reference Number. For IMPS Transfer quote
IMPS Transaction Number

For Accounts Use Only

Payment Status Received / Not Received
Receipt Number
Receipt Date

Authorized Signatory with Seal

F100/Rev 01/01.03.2018