NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots
NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots
NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots
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Panchayat/Municipality/Corporation in Kerala<br />
(tIcf¯nse ]©mb¯v/ap\n-kn-¸m-enän/tImÀ¸-td-j³)<br />
1. Name of NRK {]hmknbpsS t]cv<br />
2. Date of Birth (P\\¯obXn)<br />
3. Passport/Ration Card/Election Card or any Other Valid ID Proof No.<br />
]mkvt]mÀ«v/tdj³/Ce£³ ImÀtUm aäv AwKoIrX Xncn¨dnb tcJbpsS \¼À<br />
4. State of Residence(Xma-kn-¡p-\m\ kwkvYm\w)<br />
5. Present Address (Ct¸mgs¯ hnemkw)<br />
6. Name of Nominee with relationship (AhIminbpsS t]cpw _Ôhpw)<br />
7. Address in Kerala (tIc-f-¯nse taÂhn-em-kw)<br />
E-mail (CþsabnÂ)<br />
Telephone No with STD code (t^m¬ \¼À tImUv DÄs¸sS)<br />
8. Official Address (sXmgn sN¿p Øm]\¯nsâ hnemkw)<br />
9. Profession (sXmgnÂ)<br />
F³.-BÀ.-sI. C³jpd³kv ImÀUv<br />
At]£m^mdw<br />
(A\y-kwØm-\ a-e-bmfn)<br />
(Please read the guidelines before filling up the application. Use only CAPITAL Letters)<br />
(At]£ ]qcn-¸n-¡p--Xn\v ap³]v \n_-Ô-\-IÄ hmbn¡p-I. Cw¥ojv henb A£-c¯nÂ<br />
]qcn¸n-¡p-I)<br />
District in Kerala (tIcf¯n GXv PnÃbnemWv)<br />
ID Proof submitted (\ÂInbn«pÅ Xncn¨dnb tcJ)<br />
E-mail (CþsabnÂ)<br />
Day<br />
Znhkw<br />
Month<br />
amkw<br />
Telephone number with STD Code (t^m¬ \¼À tImUv DÄs¸sS):<br />
Signature of the NRK<br />
({]hm-kn-bpsS H¸v)<br />
(Black Ink)<br />
Year<br />
hÀjw<br />
Date of issue<br />
(\ÂInb XobXn)<br />
At]£m^mdw kuP\yamWv<br />
IfÀ t^mt«m<br />
(]mkvt]mÀ«v sskkv)<br />
P I N<br />
Name (t]cv) Relationship (_Ôw) Age (hbkv)<br />
District (PnÃ) PIN Code(]n³tImUv):<br />
Gender<br />
kv{Xo/]p-cpj³ M/F<br />
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<br />
]d-bp-- Bsf Rm³ \ma-\nÀt±iw sN¿p-p.)<br />
NORKA-ROOTS, NORKA Centre, Thycaud, Thiruvananthapuram-695 014, Kerala, India<br />
+ 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<br />
F{X Imeambn Xmakn¡pp)<br />
11. Other Details of Employment (sXmgn kw_Ôamb aäv hnhc§Ä)<br />
12. Educational Qualifications<br />
(hnZym`ymk tbmKyXIÄ)<br />
13. Whether family lives with the NRK<br />
(IpSpw_w {]hmkntbmsSm¸amtWm?)<br />
14. Marital status (sshhmlnImhØ)<br />
15. Religion (aXw)<br />
16. Details of family members including parents (amXm]nXm¡Ä DÄs¸sS IpSpw_mwK§fpsS hniZhnhcw)<br />
Declaration ({]XnÚ)<br />
Page: 2<br />
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<br />
against me. (apIfn sImSp¯ncn¡p hnhc§sfÃmw Fsâ Adn-hnÂs¸-«n-S-t¯mfw kXyamsWv Rm³ CXn\m km£ys¸Sp¯pp.<br />
GsX¦nepw hnhcw sXämsWv t_m[ys¸«m F\ns¡Xnsc \nba \S]SnIÄ kzoIcn¡mhpXmWv.).<br />
Name and Signature of the Applicant/*Family Member<br />
At]£Is‚/IpSpw_mwKØns‚ t]cpw H∏pw<br />
ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN RESIDING STATE<br />
The applicant has signed in my presence and he/she is living this state since ......................(month)................(year).<br />
ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN KERALA<br />
At]£Is\ F\n°v t\cn´dnbmw. ta¬∏d hkvXpXIƒ ]q¿Wambpw icnbmsW∂v CXn\m¬ Rm≥ km£ys∏SpØp∂p.<br />
Place (Øew) ........................................................................<br />
Date (XobXn) ........................................................................<br />
Married<br />
Code number : .............................................................<br />
Date of Registration : .............................................................<br />
ID Number : .............................................................<br />
Status : .............................................................<br />
FOR OFFICE USE ONLY<br />
hÀjw amkw<br />
Yes<br />
AsX<br />
Single Divorced<br />
Name (t]cv) Relationship (_Ôw) Age (hbÊv)<br />
No<br />
AÃ<br />
Name and Signature of the Official/Authority with seal<br />
_mv amt\-P¿ (sjUyqƒUv/\mj-W-ssekvUv _mv)/]©mbØv<br />
{]knU‚ v/hm¿Uv saº¿/Iu¨kne¿/Fw.-F¬.F/Fw.-]n.-/-tI{µ-/-kwÿm\<br />
Kk‰Uv Hm^o-k¿ t]cpw H∏pw (ko¬ klnXw)<br />
OR<br />
t]cpw H∏pw (ko¬ klnXw)<br />
]©mbØv {]knU‚ v/hm¿Uv saº¿/Iu¨kne¿/Fw.-F¬.F/Fw.-]n.-/-tI{µ-<br />
/-kw-ÿm\ Kk‰Uv Hm^o-k¿<br />
Chief Executive Officer/Authorised Officer<br />
<strong>Norka</strong>-<strong>Roots</strong>
1. Name of NRK {]hmknbpsS t]cv<br />
2. Date of Birth (P\\¯obXn)<br />
3. Present Address (Ct¸mgs¯ hnemkw)<br />
t\m¿°m˛dq´vkv F≥.-B¿.-sI. C≥jp-d≥kv Im¿Uv<br />
STATE<br />
4. Name of Nominee with relationship (AhIminbpsS t]cpw _Ôhpw)<br />
Page: 3<br />
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<br />
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.<br />
tbmKyX<br />
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¿<br />
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<br />
am-{X-am-bn-cn°pw<br />
B\p-Iq-ey-߃<br />
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<br />
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<br />
\n-b-a-߃-°v hn-t[-b-am-bn-cn°pw.<br />
At]-£n-t°≠ hn[w<br />
At]-£-I¿ At]-£-tbm-sSm∏w Xmsg ]d-bp∂ tcJ-Iƒ \¬tI-≠-XmWv.<br />
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∂<br />
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]<br />
^okmbn \¬tI-≠-XmWv (^okv 300 + t]mtÃPv 50 cq])<br />
2. c≠v ]mkvt]m¿´v sskkv t^mt´m (At]-£-bn¬ ]-Xn-°pI)<br />
3. tI{µ/kwÿm\ k¿°m-cns‚ Xncn-®-dn-b¬ tcJ/{]kvXpX tcJ-bn¬ At]-£-Is‚ \ne-hnse ta¬hn-emkw As√-<br />
n¬ At]-£-I≥ C¥ybv°v AIØv c≠p h¿-j-ambn tPmen/Xmakw/]T\w sNøp∂ kwÿm-\-Ønse hnemkw<br />
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≥<br />
Im¿Uv, ]mkvt]m¿´ tIm∏n, t^mt´m AS-ßp∂ Hm^okv sF.-Un. Im¿Uv.)<br />
IfÀ t^mt«m<br />
(]mkvt]mÀ«v sskkv)<br />
District in Kerala (tIcf¯n GXv PnÃbnemWv)<br />
E-mail (CþsabnÂ)<br />
Day<br />
Znhkw<br />
Month<br />
amkw<br />
Telephone number with STD Code (t^m¬ \¼À tImUv DÄs¸sS):<br />
Signature of the NRK<br />
({]hm-kn-bpsS H¸v)<br />
(Black Ink)<br />
Panchayat/Municipality/Corporation in Kerala (tIcf¯nse<br />
]©mb¯v/ap\n-kn-¸m-enän/tImÀ¸-td-j³)<br />
Year<br />
hÀjw<br />
P I N<br />
Gender<br />
kv{Xo/]p-cpj³ M/F<br />
Name (t]cv) Relationship (_Ôw) Age (hbkv)
Page: 4<br />
]qcn-∏n® At]£ ^okv Bh-iy-amb tcJ-Iƒ F∂nh klnXw Xmsg-]-d-bp∂ t\m¿°-˛-dq-´vkns‚ Hm^o-kp-I-fn¬<br />
ka¿∏n-t°-≠-Xm-Wv.<br />
1. t\m¿°-˛-dq-´vkv, doP-W¬ Hm^o-kv, ^Ãv ^vtfm¿, t\m¿° sk‚¿, Xncp-h-\-¥-]p-cw,<br />
t^m¨˛0471 2329950<br />
2. t\m¿°-˛-dq-´vkv, doP-W¬ Hm^o-kv, hn.-Fw. tImwπ-Ivkv, kn.-]n. DΩ¿ tdmUv, Fd-Wm-Ipfw.<br />
t^m¨˛0484 2371830, 2371810<br />
3. t\m¿°-˛-dq-´vkv, doP-W¬ Hm^o-kv, sk°‚ v ^vtfm¿, kmtam-dn≥ kvIzb¿, enn tdmUv,<br />
tImgn-t°mSv t^m¨˛0495 2304882, 2304885<br />
4. F≥.-B¿.-sI. Uh-e-]vsa‚ v Hm^o-kv, {Smh≥Iq¿ lukv, sI.-Pn. a¿Kv, \yq U¬ln 110001<br />
t^m¨˛01123384369<br />
5. F≥.-B¿.-sI. Uh-e-]vsa‚ v Hm^o-kv, tπm´v \w.8. ,sk-Iv‰¿ 30 F, tIcf lukv, hmin,<br />
apws_˛400703 t^m¨˛022 27812129<br />
6. t\m¿°-˛-dq´vkv km‰vsse‰v Hm^o-kv, sk°‚ v ^vtfm¿, kmbn _n¬Unw-Kv, satØm-SnÃv<br />
N¿®n\v FXn¿h-iw, s^‰-lvKp-\n, _tdm-U˛390002, t^m¨˛0265 2389885/2750560<br />
7. t\m¿°-˛-dq´vkv km‰vsse‰v Hm^o-kv, B¿/17, 15 kv{So‰v, AÆm \K¿, sNs∂˛600040,<br />
t^m¨˛044 26212060<br />
8. t\m¿°-˛-dq´vkv km‰vsse‰v Hm^o-kv, {io\mcm-bW kanXn _n¬UnwKv \º¿˛1,<br />
Dƒkq¿, Smv tdmUv, _mw•q¿, t^m¨˛080 25305090<br />
Im¿Uv hnX-cWw<br />
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-<br />
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<br />
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<br />
ae-bmfn s^U-td-j≥, t\m¿°-˛-dq´vkv cPn-tÿUv Atkm-kn-tb-j≥ hgntbm hnX-cWw sNøp-∂-Xm-Wv. At]-£-<br />
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-<br />
°m≥ 350 cq] bpsS DD bmWv ka¿∏n-t°-≠-Xv.