NRKInsuranceCardApplicationForm (2).pmd - 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)