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APPLICATIO N FO RM FO R Short Se rvice Commission - Ele ctrical De c 12 BATCH (UNMARRIED MALE CANDIDATES O NLY) FO R INDIAN NAVY O FFICE USE O NLY CO DE NO . VALIDITY STATUS APPLICATIO N NO -SGL1220102715

Valid

Invalid

1. CHOICE OF ENT RY[1] GS(ELECT RICAL) [2] SSC(SUB) [3] SSC(HYDRO) [4] SSC{GS(X) 2. PERSONAL PART ICULARS AS IN MAT RICULAT ION CERT IFICAT E:NAME FAT HER'S NAME DAT E OF BIRT H GENDER ANIL VO LLURI VENKATARAMANA 1990-06-28 Male

3.FAT HER'S OCCUPAT ION/DESIGNAT ION:TAILO RIING 4.NAT IONALIT Y: INDIAN 7. ADDRESS: . ADDRESS DIST RICT ST AT E PINCODE T ELEPHONE MOBILE EMAIL CORRESPONDENCE ADDRESS S/O V V RAMANA AZAY NAGAR BELAGAM PARVATHIPIRAM VIZIANAGARAM Andhra Prade sh 535501 08963 - 220084 9885527442 anil5057@gmail.com PERMANENT ADDRESS S/O V V RAMANA AZAY NAGAR BELAGAM PARVATHIPIRAM VIZIANAGARAM Andhra Prade sh 535501 08963 - 220084 --NA---NA-8(b).ST REAM: Ele ctrical 8(d).PERCENT AGE: 65.60% Marks O btaine d 7.27 5.78 5.93 6.66 2nd Semester 4th Semester 6th Semester 8th Semester Ma imum Marks 10 10 10 10 Marks O btaine d 7.27 6.23 6.42 6.92 5.DOMICILE: Andhra Prade sh 6.MARIT IAL ST AT US:Unmarrie d

8.EDUCAT ION PART ICULARS: 8(a).QUALIFICAT ION: B.E 8(c).YEAR OF EXAM PASSED: 2011 Ma imum Marks 1st Semester 3rd Semester 5th Semester 7th Semester 10 10 10 10

9.NAME AND ADDRESS OF COLLEGE WHERE ST UDIED :ANIL NEERUKO NDA INSTITUTE O F TECHNO LO GY AND SCIENCES VISAKHAPATNAM 10.NAME OF UNIVERSIT Y T O WHICH COLLEGE AFFILIAT ED AND ADDRESS:ANDHRAUNIVERSITY VISAKHAPATNAM 11. I HAVE NOT AT T ENDED ANY SSB T ILL T O DAT E WIT H T HE ARMY/NAVY OR T HE AIR FORCE. 12.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.):NO T APPLICABLE
DECLARATION 1.I, hereby declare that I am unmarried male/female, 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. 2. 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. 3. I, fully understand that in the event of any information being found false or incorrect, appropriate action can be taken against me. 4.Eligibility criteria will be verified on reporting at the selection centres. If found ineligible, I understand that criminal proceedings can be initiated against me for fraudulent entry and falsification of GOI documents. I also accept that no TA/DA will be admissible to me in such cases. 5. I have completed my B.E as on date.

Place : .............................. Date : ...............................

Signature: .............................................. Name of Applicant: ..............................

March 14, 2012, 3:25 pm
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