Wireless Planning & Coordination Wing
FORM OF APPLICATION FOR ADMISSION TO EXAMINATION FOR AWARD OF Global Maritime Distress & Safety System (GMDSS) GENERAL OPERATOR’S(GOC) CERTIFICATE
1. Name of Applicant (in Block letters) :
2. Father’s Name :
-
Full Postal Address for communication :
4. Marks of Identification :
5. Date of Birth (Attach an attested copy of :
School Leaving Certificate or Matriculation Certificate)
6. a) Are you a citizen of India by Birth and /or Domicile :
b) If not, to which country you belong (attach attested copy of Passport) :
7. Whether copy of requisite Qualification Cerificate attached:
(i) 10+2 certificate : No. Date
OR
(ii)COP/COC/COS: No. Date of expiry:
8. ( i ) Demand Drafts Number/Date/Amount :
(ii) Issue Branch with Code No. :
DECLARATION
I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing material has been concealed therefrom. I also agree that in case any information given by me herein before is found false at later date, the certificate and licence to operate, if granted, will be cancelled.
I also certify that I shall maintain Secrecy of correspondence as required under the Rules.
Place: Signature of the applicant
Date: Name (in Block letters)
-
Certified that the particulars furnished by the candidate above are true to the best of my knowledge and behalf.
-
Certified that the candidate above has undergone/has not undergone prescribed training.
Date: (PRINCIPAL)
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FOR OFFICE USE ONLY
Roll Number allotted :
Centre : NEW DELHI
Date of Examination :
Marks obtained : Part I ………………..
Part II ……………….
Result : Passed/Failed
(Witness Signature) Signature of Examination-in-Charge
Certificate/Licence Number Issued
Validity of Certificate/Licence
Signature of AWA to Govt. of India
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ATTENDANCE SHEET CUM RESULT SHEET
GMDSS GOC LICENCE NO.:
PHOTOGRAPH DATE OF ISSUE :
AWA TO GOI
1. NAME: (a) in Hindi: (b) in English:
2. FATHER’S NAME (In Eng) :
3. DATE OF BIRTH :
4. PLACE OF BIRTH :
5. NATIONALITY :
6 (a) HEIGHT (In Cms) ______ (b) COLOUR OF EYES ____________ (c) COLOUR OF HAIR________________ (d) COMPLEXION________________
7. MARKS OF IDENTIFICATION: ________________________________
8. QUALIFICATION: (a) 10+2:
(i) Certificate No.: _________________ Dated: _____________
(ii) Marks Shee No: _________________
(b) IN CASE OF COC, COP, COS Licence No. _________________valid till: ____________
9. PERMANENT ADDRESS ___________________________________________________
(WITH PIN CODE) ___________________________________________________
10. CONTACT TEL. NO./E-MAIL : ___________________________________________
CENTRE : ROLL NO.:
Signature of the candidate Date : Marks Result Signature of the Examiner : Exam-I-C/Examiner
PART:I (Written) :
PART: II (Sec.A) :
(Commercial Wkg.) :
PART: II Practical :
Examiner DGS :
Examiner, WPC :
Exam.-in-Charge :
Prov. GOC. Lic. No.--------------------------------- Issued on:---------------------------------------
Note: Staple two identical colour photographs with name, on reverse side with this form and paste one above. Necessary undertaking wherever necessary must be attached by provisionally admitted candidates.
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DECLARATION
I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing 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 required under the Rules.
Place Signature of the Applicant
Date Name
(in block letters)
1. Certified that the particulars furnished by the candidate Shri__________________________________ above are true to the best of my knowledge and belief.
2. Certified that the candidate has undergone prescribed training from ________ to _________.
Signature (…………………………….)
Name
Place: Chief Course Coordinator GMDSS
Name of the Institute
Date: Stamp of the Institute :
FOR FOREIGN NATIONALS
PERSONAL PARATICULARS OF APPLICANT
(To be submitted in six copies)
1. (a) SURNAME : NATIONALITY :
(b) NAME: PLACE OF BIRTH:
2. DATE OF BIRTH:
3. FATHER’S NAME:
4 (a) PRESENT FULL ADDRESS : PERMANENT ADDRESS :
(IN INDIA)
CITY : CITY :
STATE : STATE :
5 (a) PASSPORT NO: DATE: VALID UPTO:
(b) VISA NO. : DATE: VALID UPTO:
6. PURPOSE & PERIOD OF STAY IN INDIA:
Alongwith Full Address
7.(a) DO YOU BELONG TO DEFENCE FORCES :
OF YOUR COUNTRY?
8. ANY OTHER INFORMATION :
I hereby solemnly declare that the foregoing facts are true and correct and nothing is false therein and nothing material has been concealed there from. I also agree that in case any information given by me is found false at a later, the certificate and licence to operate, if granted, will be cancelled.
Name & Signature of Applicant
Place :
Dated :
Form of application for Renewal of
COP Licence
(Radio Telegraphy/Telephony
In
Aeronautical/Maritime Services)
C.O.P.- 23
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