8/7/13

Complete Application
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Complete Application
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Post Applied for : Applicant's Registration No :

Salutation: MR. Gender: MALE Applicant's Name Date of Birth Father's Name Mother's Name Marital Status

ADMINISTRATIVE OFFICERS (SCALE-I) NIC400387250

PICON PAL 1/1/1992 ARUP KUMAR PAL IPSITA PAL SINGLE Photo

You have ordinarily been domiciled in Kashmir Division of J & K State during the period from 01.1.1980 to 31.12.1989 Are you Resident of Assam State during the period from 01.01.1980 to 15.08.1985? Are you an Existing Confirmed Employees of Public Sector General Insurance Companies (including GIC & Agriculture Insurance Company of India Ltd.)? Are you an Ex-Serviceman Category Person With Disabilities (PWD) Citizenship Choice of State for Examination Choice of Examination Centre Journal No. of Challan Deposit Date of Challan Qualification Details: Qualifying Discipline Qualifying Degree Your Communication Details: Permanent Address: Address Line 1 MIG 1/132 MAHARANA PRATAP NAGR Village/City State Postal Address: Address Line 1 MIG 1/132 MAHARANA PRATAP NAGR Village/City State Mobile No Email Id Declaration KORBA CHHATTISGARH 918349400745 PICONPAL@REDIFFMAIL.COM KORBA CHHATTISGARH ENGINEERING B.TECH/B.E IN ANY ENGINEERING BRANCH NO GENERAL NO OTHERS DELHI DELHI 019837937 02/08/2013

NO NO NO

Address Line 2 NEAR NEARICA CHOWK Pin Code 495677

Address Line 2 NEAR NEARICA CHOWK Pin Code Landline No 495677

I hereby declare that the information given above are true and I fulfil the eligibility conditions for appearing at the pre-recruitment test conducted by National Insurance Company for the post of Administrative Officers (Scale-I). I further declare that in case of my statements are found to be false/incorrect or any ineligibility being detected before or after the Test, my candidature for the post of Administrative Officers (Scale-I) is liable to be cancelled.

_________________________ (Applicant's Signature)

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8/7/13

Complete Application
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