laLdkj kkyk

ukekadu i=
1. Full name
(in block letters)
Surname
First Name
Middle Name
2. Fathers name/Husbands name:





3. Mother's Name





4. Address for correspondence:
House No.
Mohalla/Street
City
State
Pin Code
5. Date of birth


D D M M Y Y Y Y



6. Male or Female (Tick the appropriate option)
Male
Female

7. Contact Number



8. Email Id














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2 bl i= d Hkj dj vki bls fuEu fyf[kr O;fDr;a d tek djk ldrs
gSa&

.ko tSu euh
LVhy VsM] dljxat
9413338222

vfer tSu usrk
ukdk enkj @ dljxat
9351456937

dq.kky tSu
tSu uedhu] iMk+o
9413309933

eut tSu
a1111111111
9999999999


3 bu lHkh LFkkua ij vkid uohu i= fey Hkh ldrs gSa] vFkok
vki bl QkeZ dh QV dih djk d Hkh tek djk ldrs gSaA

4 i= tek djkus dh vafre frfFk 10 e 2011 gSA



For official use only




Please affix a passport size
photograph here

Sign here :
cky
x.ksk
ekyh
iky chNyk
eafnj
9999999999

gjh Hkk
ekyh
dljxat eafnj
9999999999

AAAAAAAAA
ekyh
enkj eafnj
9999999999

tSu Vsyj
dljxat
9999999999



Allotted class
fdkj
;qok
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