GOVERNMENT OF INDIA

MINISTRY OF COMMUNICATIONS
WIRELESS PLANNING AND COORDINATION WING, DoT
FORM OF APPLICATION FOR ADMISSION TO EXAMINATION
FOR AWARD OF GMDSS CERTIFICATE

Application ID - EXG020820240100994 Exam Centre - Mumbai Month - January

1. Name of Applicant (in Block Letter) HARSHVARDHAN

2. Father's Name ANIL KUMAR SINGH

3. Address SINGH TIMBER NEAR DIGHA POLICE

STATION PS- DIGHA , PATNA , BIHAR
BIHAR Patna PIN : 800011
(L) (m) 7338991635
(eMail) harshverdhanrajput33@gmail.com

4. Mark of Identification MOLE ON LEFT HAND LITTLE FINGER

5. Date of Birth (Attach an attested copy 20-03-1999

of School Leaving Certificate or
Metriculation Certificate or Passport)

6. a Nationality Indian

b Passport No. (attach Attested copy of P6185523

Passport)

c Passport Expiry Date 09-02-2027

7. i Whether copy of 10+2 Certificate Yes

(with Physics & Maths) is attached

DECLARATION

I hereby solemnly declare and say that foregoing facts are true and correct and nothing is false there in and no material has been
concealed therefrom. I also agree that in case any information given by me herein before is found false at a later date, the certificate
and licence to operate, if granted, will be cancelled.

I also certify that I shall maintain secrecy of correspondence as requird under rules.

The submitted self-certified documents may be verified from the issuing authority, in case any discrepancy is found, application is
liable to be rejected and/or any issued certificate will be immediately revoked and suitable penal action will be taken against the
candidate.

Signature of the applicant

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 ( HARSHVARDHAN )

Date: 03-01-2024

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