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  Personal Information

Note/Instructions:
1. Please do not use any prefix such as Mr or Ms.
2. Name as recorded in the matriculation/secondary examination marksheet.
3. Name (Candidate’s/Father’s/Mother’s Name) given in the application and all the uploaded documents i.e. ID
Card, educational certificates, category certificate (SC/ST/OBC/EWS) or any other uploaded document
should be same or else the candidature will be cancelled.
4. E-mail ID and mobile number once entered can’t be changed during the entire recruitment process.
5. Candidate is to bring same ID card (provided here) in original at all stages of recruitment.
6. Two different identification marks such as birthmark, mole and burn/injury mark are to be entered as text.
7. Candidate to upload class 10th marksheet with date of birth mentioned on certificate as date of birth proof
or else Birth certificate to be uploaded.
8. Candidate is to scan the original documents (neither photocopy nor self-attested photocopy) to upload in
the online application.
9. Scanned document should be saved in .jpeg / .jpg format and size should be between 50KB to 150KB.
10. All the uploaded documents uploaded must be in Hindi or English. If, the document is in any language
other than English or Hindi then candidate is to upload both original and English translation of document as
one file/document (after merging both documents) in the online application.
11. Click here for specimen of document.
12. SC candidate availing their respective quota, must ensure that valid category certificate should have been
issued (date of issue) on or before the closing date of application.

NAME Mohit Kumar FATHER'S Narendra Pal MOTHER'S Rajbala Devi

NAME NAME
Singh
EMAIL ID mohitsuryavanshi1985 MOBILE 917895315517 ALTERNAT 919084915645
@gmail.com E MOBILE

NATIONALI Indian MARITAL Unmarried GENDER Male

TY STATUS

AADHAR XXXXXXXX7807 ID CARD Aadhaar Card ID CARD XXXXXXXX780

NUMBER
NUMBER 7

IDENTIFICA Small Cut Near Eye IDENTIFICA Mole On Foot CATEGORY Scheduled
TION MARK TION MARK
1 2
Caste (SC)

DATE OF 17-Oct-2022 DATE OF 20-Oct-2005 DATE OF 10th Class

ISSUE OF BIRTH BIRTH
CATEGORY PROOF
Marksheet/Cer
CERTIFICAT TYPE tificate
E

SECONDAR officialsauravch AGE No FEE Yes

Y EMAIL ID RELAXATIO WAVIER
auhan@gmail.c N CLAIMED
om
EMPLOYME Unemployed COMMUNIT Always valid GOT Whatsapp
NT TYPE Y INFORMATI
CERTIFICAT
(no validity date ON ABOUT
E VALIDITY mentioned on INDIAN
certificate) COAST
GUARD
RECRUITM
ENT

ID Proof (Aadhaar Card) Date of Birth Proof (10th Class

Marksheet/Certificate)

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  Post Selection

POST Navik(GD)
APPLIE
D

  Class 10th Details

Note/Instructions:
1. 10th marksheet and certificate need to be uploaded at Stage-II.
2. In case of CGPA or Grade, conversion formula document need to be uploaded at Stage-II.
3. If you have additional certificate, the document of the same need to be uploaded at Stage-II.

EDUCATIO U.P. Board of GRADING Percentage DO YOU No

N BOARD SYSTEM AS HAVE
High School & INDICATED ADDITIONA
Intermediate IN L
Education MARKSHEE MARKSHEE
T T

10TH 0272295 YEAR OF 2020 NO. OF 6

CERTIFICAT PASSING SUBJECTS
E NUMBER IN CLASS
10TH

Subject Mathematics English Hindi Science Drawing Social Sciences

Marks Obtained 73 80 81 81 77 80

Total Marks 100 100 100 100 100 100

  Class 12th Details

Note/Instructions:
1. 12th marksheet and certificate need to be uploaded at Stage-II.
2. In case of CGPA or Grade, conversion formula document need to be uploaded at Stage-II.
3. If you have additional certificate, the document of the same need to be uploaded at Stage-II.

EDUCATIO U.P. Board of GRADING Percentage DO YOU No

N BOARD SYSTEM HAVE
High School & INDICATED ADDITIONA
Intermediate IN L
Education MARKSHEE MARKSHEE
T T

12TH 0222910 YEAR OF 2022 NO. OF 5

CERTIFICAT PASSING SUBJECTS
E NUMBER IN CLASS
12TH

Subject Physics Mathematics Chemistry English Hindi

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Marks Obtained 69 82 82 72 84

Total Marks 100 100 100 100 100

  Additional Details

1) HAVE YOU BEEN DISCHARGED FROM THE INDIAN ARMY / INDIAN NAVY / INDIAN AIR FORCE No
OR ANY GOVERNMENT ORGANIZATION ?
2) HAS ANY WARRANT OR SUMMONS FOR YOUR APPEARANCE AS WITNESS BEEN ISSUED AND No
PENDING BEFORE A COURT OF LAW FOR THE TIME BEING IN FORCE ?
3) ARE ANY PROCEEDINGS IN RESPECT OF AN OFFENCE ALLEGED TO HAVE BEEN COMMITTED No
BY YOU PENDING BEFORE A CRIMINAL COURT IN INDIA ?
4) HAS ANY WARRANT OR SUMMONS FOR YOUR OFFENCE BEEN ISSUED AND PENDING BEFORE No
A COURT OF LAW FOR THE TIME BEING IN FORCE ?
5) HAS A WARRANT FOR YOUR ARREST BEEN ISSUED BY A COURT UNDER ANY LAW FOR THE No
TIME BEING IN FORCE ?
6) HAVE YOU, AT ANY TIME PRECEDING THE DATE OF THIS APPLICATION, BEEN CONVICTED BY A No
COURT OF INDIA FOR ANY OFFENCE AND SENTENCED IN RESPECT THEREOF TO IMPRISONMENT
?
7) HAVE YOU APPLIED IN HIGHER COURT FOR ACQUITTAL AGAINST THE CONVICTION OF LOWER No
COURT ?
8) HAVE YOU EVER BEEN DEBARRED BY ICG / ARMY / NAVY / AIR FORCE / UPSC / CENTRAL OR No
STATE GOVT. DURING ANY RECRUITMENT PROCESS ?

  Communication Details

Note/Instructions:
1. In case of reserved category applicants, either current or permanent address of online application should
be same as the address mentioned in caste/category certificate (SC, ST, OBC(Non-Creamy Layer) & EWS).

Permanent Address
HOUSE/ST Sonda Habibpur LANDMARK khurja junction POST sonda habibpur
REET OFFICE
Khurja Bulandshahr
COUNTRY India STATE/ UT UTTAR PRADESH DISTRICT Bulandshahr
SUB Khurja PIN CODE 203132 PHONE NO 7895315517
DISTRICT WITH AREA
CODE

Present/Current Address
HOUSE/ST Sonda Habibpur LANDMARK khurja junction POST sonda habibpur
REET OFFICE
Khurja Bulandshahr
COUNTRY India STATE/ UT UTTAR PRADESH DISTRICT Bulandshahr
SUB Khurja PIN CODE 203132 PHONE NO 7895315517
DISTRICT WITH AREA
CODE

Domicile Details
DOMICILE Uttar Pradesh
STATE

  Photo and Signature

Note/Instructions:
1. Click here for specimen of photograph.
2. While uploading Photo / Signature / Thumb image, file nomenclature should be as follows:
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Passport photograph: Passport_Photograph

Scanned signature image: Signature
Left hand thumb impression image: Thumb_Impression
3. Any discrepancy or anomaly in clarity of images of uploaded documents in the online application will lead
to cancellation of candidature.

PHOTO LEFT HAND THUMB IMPRESSION IMAGE SIGNATURE

  Stage - I - Exam City Preferences

Note/Instructions:
1. Candidates are to fill first choice within 30 kms from the present residence. In case if no centre is available
within 30 kms then the other choices should be nearest to the present address.
2. Your next 4 preferences nearest to present address in increasing order of distance.
3. Non-compliance to these instructions may lead to cancellation of your candidature during document
verification.

1. Ghaziabad 2. 3. Delhi and NCR4. Meerut 5. Kanpur

Noida/Greater
Noida

  Stage - II - Exam City Preferences

1. Noida 2. Kolkata 3. 4. Goa 5. Port Blair

Visakhapatana
m

  Uploaded Documents

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ID PROOF (AADHAAR CARD)

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DATE OF BIRTH PROOF (10TH CLASS

MARKSHEET/CERTIFICATE)

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COMMON REASONS FOR REJECTION DURING

DOCUMENT VERIFICATION

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COMMON REASONS FOR REJECTION DURING

DOCUMENT VERIFICATION

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COMMON REASONS FOR REJECTION DURING

DOCUMENT VERIFICATION

 Declaration

CI khurja DA 09-09-2023
TY TE

* *

I hereby declare that all the above information provided by me is correct.

I owe allegiance to the sovereignty, unity and integrity of India. I have not lost, surrendered or been
deprived of the citizenship of India.
I am eligible to apply for the said rank category as per the Indian Coast Guard (ICG) advertisement for
present batch and have also read the FAQs and common reasons for rejection during various stages of
recruitment given on website.
I declare that I have applied for only one post viz. either Navik (DB) or Navik (GD) or Yantrik (Mechanical)
or Yantrik (Electrical) or Yantrik (Electronics) in present cycle. I understand that if, multiple applications
are filled by me, then ,only the latest filled application will be accepted and all the other applications
will be rejected and the exam fee paid against these applications will not be refunded.
I declare to remember my mobile number and E-mail ID used during filling of online application, as, the
primary mode of communication of ICG with me will be either through ICG website or E-mail.
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I understand that Coast Guard will be uploading E-admit card, result of various stages of recruitment in
my login dashboard and will also be publishing various updates/announcements regarding
recruitment on Coast Guard recruitment website. Hence, I declare to visit ICG website and my login
dashboard on regular/daily basis. ICG will not be responsible if I fail to visit ICG website on a daily basis
and comply with the instructions therein given from time to time and will not claim re-examination.
I understand that capturing and verification of biometric impression is mandatory for appearing at all
stages of recruitment.
I understand that Indian Coast Guard reserves the right to conduct assessment/adaptability of
candidates at any stage of the recruitment process, prior issue of appointment letter to avoid
impersonation. I understand that my candidature can be cancelled on account of impersonation and
the decision of Indian Coast Guard will be final and binding on me in this regard.
I understand that my candidature will be cancelled and I will be debarred from future Coast Guard
Recruitment examinations in case I am found to be involved in malpractice during any stage of current
recruitment process.
I affirm that the information and particulars given by me in this application are true/correct and I am
not suppressing any material information in this regard. I further affirm that the certificates (ID
Proof/DOB proof/NOC/Domicile certificate) uploaded in support of my application for recruitment of
the said post are authentic and solely pertain to me and I am fully responsible for the accuracy of the
same.
I declare that my SC/ST/OBC (non-creamy layer)/EWS certificate comply with the instructions given in
the advertisement regarding the format of certificate for appointment to the post under Government of
India. If my candidature is cancelled on account of incorrect category document then I shall not be
considered against unreserved vacancy as I have submitted false information.
I certify that I am in possession of originals of all the documents uploaded in the online application.
Failure to present the original document as uploaded in online application on account of loss of
documents will lead to cancellation of candidature. I understand that no request in this regard will be
entertained by ICG even if I produce an F.I.R. w.r.t. theft of my documents and my candidature will stand
cancelled.
I declare that the form is filled by myself and not any other person, and for any mismatch/wrong
information/incorrect photo/signature/thumb image uploads, I will be responsible. I am aware that,
my candidature can be cancelled, in case of any mismatch/wrong information.
I have completely checked the print preview of the application and I certify that my application is
correct in all aspects as per the advertisement.
NO CLAIM / RISK UNDERTAKING:- I am a candidate for recruitment in Indian Coast Guard. I give my full
and free consent at my own risk that I shall not be entitled to claim any compensation or other relief
from the government in respect of any injury or disability which I may sustain in the course of or as the
result of any of the tests (both physical fitness test and medical test) administrated to me or attended
by me during the recruitment procedure, whether due to my own negligence or any other person or
otherwise.

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 Checking for print preview

Note/Instructions:
1. You are directed to completely check the print preview of the application and certify that your
application is correct in all aspects as per the advertisement. You are directed to go through the
common reasons for rejection as published on the website and certify that your application is correct
and does not fall for rejection in document verification as per the rules prescribed in the advertisement
for Stage-I, II & III as published on the website. You may edit the application and the uploaded
documents if there is any mistake or error before submitting the application. Once the application is
submitted, no changes are allowed.
HAVE YOU SEEN THE PRINT PREVIEW BEFORE SUBMITTING THE APPLICATION ? YES NO

DO YOU WANT TO EDIT THE APPLICATION OR THE UPLOADED DOCUMENTS IF THE DETAILS IN
YES NO
YOUR APPLICATION ARE INCORRECT OR THE DOCUMENTS ARE INCORRECTLY UPLOADED ?

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DID YOU UTILIZE THE "EDIT" OPTION AFTER SEEING THE PRINT PREVIEW PRIOR FINAL SUBMISSION
YES NO
?

DO YOU WANT TO SUBMIT THE APPLICATION FINALLY ?

YES NO
IF YOU CHECK YES, YOUR APPLICATION WILL BE SUBMITTED AND NO CHANGES WILL BE
ALLOWED FURTHER.

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