10/25/2018 :: ONLINE APPLICATION ::

INDIAN COAST GUARD

ONLINE APPLICATION FORM
Application No. : 219/668265 Roll No. :
Affix recent
(1) Name of the post applied for : Domestic Branch passport size
colour Photo
(2)
Centre at which you wish to appear for Test :
Date and Time of Reporting at Centre :

Centre
Priority Full Address of the Centre
Name
CHENNAI COAST GUARD STORE DEPOT CHENNAI, GM PETTAI
1
- CH ROAD, ROYAPURAM, CHENNAI, TAMIL NADU – 600 013

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

HARIPRATHAP R Gender : Male
(4) Current postal address :
2/115 VALLIPATTU VILLAGE AND POST VANIYAMBADI TALUK, CITY: VANIYAMBADI,
STATE: TAMIL NADU, DISTRICT : VELLORE, PIN : 635752
(5) Permanent address :
2/115 VALLIPATTU VILLAGE AND POST VANIYAMBADI TALUK, CITY: VANIYAMBADI,
STATE: TAMIL NADU, DISTRICT : VELLORE, PIN : 635752
(6) E-mail ID : hariprathap24748@gmail.com Mobile No : +918248766366
(7) Mother's name : KOKILA K
(8) Father's name : RATHINAVEL G
(9) Category : OBC (10) Date of Birth : 10 May 1997 (11) Nationality : Indian
(12) Qualification :
Compl. Compl. Year of
Qualification Board/Institution AggrPercent
Subject Mark Passing
STATE BOARD OF SCHOOL
EXAMINATIONS (SEC.) &
BOARD OF HIGHER
10th 84.6 --NA-- 0 2012
SECONDARY
EXAMINATIONS, TAMIL
NADU
STATE BOARD OF SCHOOL
EXAMINATIONS (SEC.) &
BOARD OF HIGHER
12th 81.17 --NA-- 0 2014
SECONDARY
EXAMINATIONS, TAMIL
NADU
(13) Knowledge of Swimming : NO
(14) Proficiency in sports, National Level (attach photocopies of certificate) : NO
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10/25/2018 :: ONLINE APPLICATION ::

(15) NCC certificate obtained (attach photocopy of certificate, if yes) : --NA--

(16) Marital Status : Unmarried
(17) Is Wards of Coast Guard uniform personnel deceased while in service : NO
(18) Is your father serving /retired from Defence : NO
(19) Is Service Personnel : NO
(20) 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 : VANIYAMBADI Signature :
Name of the Applicant :
Date : 25/10/2018
HARIPRATHAP R
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