2/10/2018 :: ONLINE APPLICATION ::

INDIAN COAST GUARD

ONLINE APPLICATION FORM
Application No. : 418/506199 Roll No. :
Affix recent
(1) Name of the post applied for : Domestic Branch
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, OPPOSITE
NOIDA
1 HCL TECHNOLOGIES LTD., DISTRICT-GAUTAMBUDHA NAGAR,
- NO
NOIDA, UP – 201 301

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

AVNESH KUMAR Gender : Male
(4) Current postal address:
VILL AND POST BEETHANA DIST ALIGARH, CITY: ALIGARH, STATE: UTTAR PRADESH,
DISTRICT : ALIGARH, PIN : 202001
(5) Permanent address:
VILL AND POST BEETHANA DIST ALIGARH, CITY: ALIGARH, STATE: UTTAR PRADESH,
DISTRICT : ALIGARH, PIN : 202001
(6) E-mail ID : avaneshkumar91@gmail.com Mobile No : +919634126210
(7) Mother's name : RANI DEVI (8) Aadhaar No.
(9) Father's name : CHARAN SINGH
(10) Category SC (11) Date of Birth 20 Feb 1995 (12) Nationality : Indian
(13) Qualification
Compl. Compl. Year of
Qualification Board/Institution AggrPercent
Subject Mark Passing
U.P. BOARD OF HIGH
10th SCHOOL & INTERMEDIATE 70.33 --NA-- 0 2013
EDUCATION
(14) Knowledge of Swimming : NO
(15) Proficiency in sports, National Level (attach photocopies of certificate) : NO
(16) NCC certificate obtained (attach photocopy of certificate, if yes) : --NA--
(17) Marital Status : Unmarried
(18) Is Wards of Coast Guard uniform personnel deceased while in service : NO
(19) Is your father serving /retired from Defence : NO
(20) Is Service Personnel : 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 : ALIGARH Signature :
Name of the Applicant : AVNESH
Date : 10/02/2018
KUMAR

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2/10/2018 :: ONLINE APPLICATION ::

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