NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots

Panchayat/Municipality/Corporation in Kerala
(tIcf¯nse ]©mb¯v/ap\n-kn-¸m-enän/tImÀ¸-td-j³)
1. Name of NRK {]hmknbpsS t]cv
2. Date of Birth (P\\¯obXn)
3. Passport/Ration Card/Election Card or any Other Valid ID Proof No.
]mkvt]mÀ«v/tdj³/Ce£³ ImÀtUm aäv AwKoIrX Xncn¨dnb tcJbpsS \¼À
4. State of Residence(Xma-kn-¡p-\m\ kwkvYm\w)
5. Present Address (Ct¸mgs¯ hnemkw)
6. Name of Nominee with relationship (AhIminbpsS t]cpw _Ôhpw)
7. Address in Kerala (tIc-f-¯nse taÂhn-em-kw)
E-mail (CþsabnÂ)
Telephone No with STD code (t^m¬ \¼À tImUv DÄs¸sS)
8. Official Address (sXmgn sN¿p Øm]\¯nsâ hnemkw)
9. Profession (sXmgnÂ)
F³.-BÀ.-sI. C³jpd³kv ImÀUv
At]£m^mdw
(A\y-kwØm-\ a-e-bmfn)
(Please read the guidelines before filling up the application. Use only CAPITAL Letters)
(At]£ ]qcn-¸n-¡p--Xn\v ap³]v \n_-Ô-\-IÄ hmbn¡p-I. Cw¥ojv henb A£-c¯nÂ
]qcn¸n-¡p-I)
District in Kerala (tIcf¯n GXv PnÃbnemWv)
ID Proof submitted (\ÂInbn«pÅ Xncn¨dnb tcJ)
E-mail (CþsabnÂ)
Day
Znhkw
Month
amkw
Telephone number with STD Code (t^m¬ \¼À tImUv DÄs¸sS):
Signature of the NRK
({]hm-kn-bpsS H¸v)
(Black Ink)
Year
hÀjw
Date of issue
(\ÂInb XobXn)
At]£m^mdw kuP\yamWv
IfÀ t^mt«m
(]mkvt]mÀ«v sskkv)
P I N
Name (t]cv) Relationship (_Ôw) Age (hbkv)
District (PnÃ) PIN Code(]n³tImUv):
Gender
kv{Xo/]p-cpj³ M/F
I nominate the above person for claiming the insurance benefit, in the event of my death. ( B\p-Iq-ey-§Ä ssI¸-äp--Xn\v apI-fnÂ
]d-bp-- Bsf Rm³ \ma-\nÀt±iw sN¿p-p.)
NORKA-ROOTS, NORKA Centre, Thycaud, Thiruvananthapuram-695 014, Kerala, India
+ 91-471-2332416, 2332452 Fax:+91-471-2326263, e_mail: mail@norkaroots.net, URL: www.norkaroots.net, www.norka.gov.in

10. a) Duration of stay in Other State (A\ykwØm\¯v
F{X Imeambn Xmakn¡pp)
11. Other Details of Employment (sXmgn kw_Ôamb aäv hnhc§Ä)
12. Educational Qualifications
(hnZym`ymk tbmKyXIÄ)
13. Whether family lives with the NRK
(IpSpw_w {]hmkntbmsSm¸amtWm?)
14. Marital status (sshhmlnImhØ)
15. Religion (aXw)
16. Details of family members including parents (amXm]nXm¡Ä DÄs¸sS IpSpw_mwK§fpsS hniZhnhcw)
Declaration ({]XnÚ)
Page: 2
I declare that the details given above are true to the best of my knowledge and belief. If anything stated is found false, legal action may be taken
against me. (apIfn sImSp¯ncn¡p hnhc§sfÃmw Fsâ Adn-hnÂs¸-«n-S-t¯mfw kXyamsWv Rm³ CXn\m km£ys¸Sp¯pp.
GsX¦nepw hnhcw sXämsWv t_m[ys¸«m F\ns¡Xnsc \nba \S]SnIÄ kzoIcn¡mhpXmWv.).
Name and Signature of the Applicant/*Family Member
At]£Is‚/IpSpw_mwKØns‚ t]cpw H∏pw
ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN RESIDING STATE
The applicant has signed in my presence and he/she is living this state since ......................(month)................(year).
ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN KERALA
At]£Is\ F\n°v t\cn´dnbmw. ta¬∏d hkvXpXIƒ ]q¿Wambpw icnbmsW∂v CXn\m¬ Rm≥ km£ys∏SpØp∂p.
Place (Øew) ........................................................................
Date (XobXn) ........................................................................
Married
Code number : .............................................................
Date of Registration : .............................................................
ID Number : .............................................................
Status : .............................................................
FOR OFFICE USE ONLY
hÀjw amkw
Yes
AsX
Single Divorced
Name (t]cv) Relationship (_Ôw) Age (hbÊv)
No
AÃ
Name and Signature of the Official/Authority with seal
_mv amt\-P¿ (sjUyqƒUv/\mj-W-ssekvUv _mv)/]©mbØv
{]knU‚ v/hm¿Uv saº¿/Iu¨kne¿/Fw.-F¬.F/Fw.-]n.-/-tI{µ-/-kwÿm\
Kk‰Uv Hm^o-k¿ t]cpw H∏pw (ko¬ klnXw)
OR
t]cpw H∏pw (ko¬ klnXw)
]©mbØv {]knU‚ v/hm¿Uv saº¿/Iu¨kne¿/Fw.-F¬.F/Fw.-]n.-/-tI{µ-
/-kw-ÿm\ Kk‰Uv Hm^o-k¿
Chief Executive Officer/Authorised Officer
Norka-Roots

1. Name of NRK {]hmknbpsS t]cv
2. Date of Birth (P\\¯obXn)
3. Present Address (Ct¸mgs¯ hnemkw)
t\m¿°m˛dq´vkv F≥.-B¿.-sI. C≥jp-d≥kv Im¿Uv
STATE
4. Name of Nominee with relationship (AhIminbpsS t]cpw _Ôhpw)
Page: 3
C¥y-bnse a‰v kwÿm-\-ß-fn¬ Xma-kn-°p∂/tPmen sNøp∂ ae-bm-fn-Iƒ°v tIcf k¿°m-cns‚ t\m¿°-˛-dq´vkv
Hcp sF.-Un. Im¿Uv Iw C≥jp-d≥kv Im¿Uv ]≤Xn \S-∏m-°n-h-cp-∂p. Im¿Uns‚ Imem-h[n 3 h¿j-am-bn-cn°pw.
tbmKyX
18 hb p XnI--hcpw c≠v h¿jtam AXn¬ IqSp-Xtem tIc-f-Øn\v ]pdØv (C-¥ybv°v AI-Øv) tPmen sNbvXph-cp-∂-h¿
As√-n¬ tIc-f-Øn\v ]pdØv ÿncw Xma-kn-°p-∂-h¿. C≥jz-d≥-kv ]-cn-c-£ ]-c-am-h-[n 70 h-b- ph-sc
am-{X-am-bn-cn°pw
B\p-Iq-ey-߃
Im¿Uv DS-abv°v 2 e£w cq]-bpsS A]-IS acW C≥jp-d≥kv ]cn-c-£bpw A]-I-S-Øn¬ ÿnc AwK-ssh-Ieyw
kw`-hn-®m¬ 2 e£w cq]bpw `mKn-I-amb AwK-ssh-I-ey-Øn\v 1 e£w cq]bpw e`n-°p-∂-Xm-Wv. B\p-Iq-ey-߃ C≥-jzd≥-kv
\n-b-a-߃-°v hn-t[-b-am-bn-cn°pw.
At]-£n-t°≠ hn[w
At]-£-I¿ At]-£-tbm-sSm∏w Xmsg ]d-bp∂ tcJ-Iƒ \¬tI-≠-XmWv.
1. At]£ ^okv 300 cq]. (No^v FIvkn-Iyq-´ohv Hm^o-k¿, t\m¿°-˛-dq´vkv F∂ t]cn¬ Xncp-h-\-¥-]p-cØv amdmhp∂
Un.-Un.-bmbn \¬IWw.) C≥jp-d≥kv Im¿Un\p≈ At]£ t\cn´v Hm^o-kn-tebv°v Ab-°p-∂-h¿ 350 cq]
^okmbn \¬tI-≠-XmWv (^okv 300 + t]mtÃPv 50 cq])
2. c≠v ]mkvt]m¿´v sskkv t^mt´m (At]-£-bn¬ ]-Xn-°pI)
3. tI{µ/kwÿm\ k¿°m-cns‚ Xncn-®-dn-b¬ tcJ/{]kvXpX tcJ-bn¬ At]-£-Is‚ \ne-hnse ta¬hn-emkw As√-
n¬ At]-£-I≥ C¥ybv°v AIØv c≠p h¿-j-ambn tPmen/Xmakw/]T\w sNøp∂ kwÿm-\-Ønse hnemkw
sXfn-bn-°p-∂ tcJ \¬tI-≠-Xp-≠v. (hm-S-I-No-´v, hm´¿ IW-£≥ _n√v, Id≠v_n√v, sSe-t^m¨ _n√v, tdj≥
Im¿Uv, ]mkvt]m¿´ tIm∏n, t^mt´m AS-ßp∂ Hm^okv sF.-Un. Im¿Uv.)
IfÀ t^mt«m
(]mkvt]mÀ«v sskkv)
District in Kerala (tIcf¯n GXv PnÃbnemWv)
E-mail (CþsabnÂ)
Day
Znhkw
Month
amkw
Telephone number with STD Code (t^m¬ \¼À tImUv DÄs¸sS):
Signature of the NRK
({]hm-kn-bpsS H¸v)
(Black Ink)
Panchayat/Municipality/Corporation in Kerala (tIcf¯nse
]©mb¯v/ap\n-kn-¸m-enän/tImÀ¸-td-j³)
Year
hÀjw
P I N
Gender
kv{Xo/]p-cpj³ M/F
Name (t]cv) Relationship (_Ôw) Age (hbkv)

Page: 4
]qcn-∏n® At]£ ^okv Bh-iy-amb tcJ-Iƒ F∂nh klnXw Xmsg-]-d-bp∂ t\m¿°-˛-dq-´vkns‚ Hm^o-kp-I-fn¬
ka¿∏n-t°-≠-Xm-Wv.
1. t\m¿°-˛-dq-´vkv, doP-W¬ Hm^o-kv, ^Ãv ^vtfm¿, t\m¿° sk‚¿, Xncp-h-\-¥-]p-cw,
t^m¨˛0471 2329950
2. t\m¿°-˛-dq-´vkv, doP-W¬ Hm^o-kv, hn.-Fw. tImwπ-Ivkv, kn.-]n. DΩ¿ tdmUv, Fd-Wm-Ipfw.
t^m¨˛0484 2371830, 2371810
3. t\m¿°-˛-dq-´vkv, doP-W¬ Hm^o-kv, sk°‚ v ^vtfm¿, kmtam-dn≥ kvIzb¿, enn tdmUv,
tImgn-t°mSv t^m¨˛0495 2304882, 2304885
4. F≥.-B¿.-sI. Uh-e-]vsa‚ v Hm^o-kv, {Smh≥Iq¿ lukv, sI.-Pn. a¿Kv, \yq U¬ln 110001
t^m¨˛01123384369
5. F≥.-B¿.-sI. Uh-e-]vsa‚ v Hm^o-kv, tπm´v \w.8. ,sk-Iv‰¿ 30 F, tIcf lukv, hmin,
apws_˛400703 t^m¨˛022 27812129
6. t\m¿°-˛-dq´vkv km‰vsse‰v Hm^o-kv, sk°‚ v ^vtfm¿, kmbn _n¬Unw-Kv, satØm-SnÃv
N¿®n\v FXn¿h-iw, s^‰-lvKp-\n, _tdm-U˛390002, t^m¨˛0265 2389885/2750560
7. t\m¿°-˛-dq´vkv km‰vsse‰v Hm^o-kv, B¿/17, 15 kv{So‰v, AÆm \K¿, sNs∂˛600040,
t^m¨˛044 26212060
8. t\m¿°-˛-dq´vkv km‰vsse‰v Hm^o-kv, {io\mcm-bW kanXn _n¬UnwKv \º¿˛1,
Dƒkq¿, Smv tdmUv, _mw•q¿, t^m¨˛080 25305090
Im¿Uv hnX-cWw
At]£ ka¿∏n-°p∂ Hm^o-kn¬\n∂pw C≥jp-d≥kv Im¿Uv hnX-cWw sNøp-∂-Xm-Wv. t\m¿°-˛-dq-´vkns‚ Hm^o-kp-
Iƒ C√mØ ÿe-ß-fn¬ \n∂pw X]m¬ am¿Kw t\m¿°-˛-dq´vkv slUv Hm^o-kn-tebv°v At]-£-Iƒ Ab-bv°p-∂-h-cpsS
C≥jp-d≥kv Im¿Up-Iƒ Ah-cpsS tIc-f-Ønse hnem-k-Øn¬ ]d-n-cn-°p∂ Pn√-bnse t\m¿° sk√v, a‰v kwÿm-\ß-fnse
ae-bmfn s^U-td-j≥, t\m¿°-˛-dq´vkv cPn-tÿUv Atkm-kn-tb-j≥ hgntbm hnX-cWw sNøp-∂-Xm-Wv. At]-£-
It\m Ah-cpsS {]Xn-\n-[nt°m Im¿Uv ssI∏-‰m-hp-∂-Xm-Wv. X]m¬ am¿§w Xß-fpsS \ne-hnse ta¬hn-em-k-Øn¬ e`n-
°m≥ 350 cq] bpsS DD bmWv ka¿∏n-t°-≠-Xv.