NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots
NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots
NRKInsuranceCardApplicationForm (2).pmd - Norka- Roots
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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>
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