NRK ID Card (Correction) - NORKA ROOTS

1 {]hmkn Xncn dnb Im Uv At] m^mdw (hntZ-i a-e-bmfn). At] m^mdw kuP\yamWv If t^mt m (]mkvt]m v sskkv). (Please read the guidelines before filling up the application. Use only CAPITAL Letters). (At] ]qcn- n- p- -Xn\v ap ]v \n_- -\-I hmbn p-I. Cw ojv henb A -c n . ]qcn n- p-I). District (Pn ). Signature of the NRK. Panchayat/Municipality/Corporation ({]hm-kn-bpsS H v). (] mb v/ap\n-kn- m-en n/tIm -td-j ) (Black Ink). 1. Name (as in passport) t]cv (]mkvt]m n D Xpt]mse). 2. Date of Birth (P\\ obXn) Day Month Year Gender M/F. Znhkw amkw h jw kv{Xo/]p-cpj . 3. Passport Number (]mkvt]m v \ ) Place of issue (\ Inb ew) Date of issue (\ Inb XobXn). Day Month' Year Znhkw amkw h jw 4. Country of Residence (Ct m Xma-kn- p cmPyw). 5. Address for communication (I -b-bv p- -Xn-\p hnemkw) (kztZ-iw). P I N. E-mail (C sabn ). Telephone No with ISD code (t^m \ tImUv D s sS).}}}

2 6. Name of Nominee with relationship (AhIminbpsS t]cpw _ hpw). I nominate the following person for claiming the insurance benefit, in the event of my death. ( B\p-Iq-ey- ssI - p- -Xn\v Xmsg ]d-bp- - Bsf Rm \ma-\n t iw sN p- p.). Name (t]cv) Relationship (_ w) Age (hbkv). 7. Address abroad (hntZis hnemkw). 8. Address in Passport (]mkvt]m nse hnemkw). District (Pn ) PIN Code(]n tImUv) : 9. Profession (sXmgn ). 10. a) Duration of overseas stay (hntZi v F{X Imeambn Xmakn p p) h jw amkw NORKA - ROOTS , NORKA Centre, Thycaud, Thiruvananthapuram-695 014, Kerala, India ( + 91-471-2332416, 2332452 Fax:+91-471-2326263, e_mail: URL: , Page: 2. 11. Details of Sponsor (kvt]m kdpsS hnhc ). 12. Educational Qualifications (hnZym`ymk tbmKyXI ). 13. Whether family lives abroad or in native place In native place Abroad (IpSpw_w hntZit mtWm kztZi mtWm) hntZi v kztZi v 14.}

3 Marital status (sshhmlnImh ) Married Single Divorced 15. Religion (aXw). 16. Details of family members including parents (amXm]nXm D s sS IpSpw_mwK fpsS hniZhnhcw). Name (t]cv) Relationship (_ w) Age (hb v). Declaration ({]Xn ). 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 against me. (apIfn sImSp ncn p hnhc sf mw Fs Adn-hn s - n-S-t mfw kXyamsW v Rm CXn\m km ys Sp p p. GsX nepw hnhcw sX msW v t_m[ys m F\ns Xnsc \nba \S]SnI kzoIcn mhp XmWv.). Name and Signature of the Applicant/*Family Member At] Is /IpSpw_mwK ns t]cpw H pw ATTESTATION FROM INDIAN EMBASSY / CONSULATE ABROAD / OFFICE BEARERS OF. RECOGNISED NRK ASSOCIATION ABROAD. The applicant has signed in my presence and he/she is living this country since ..(month).}

4 (year). Name and Signature of the Embassy/Consulate Official with seal OR t\m dq vkns AwKo-IrX ] n-I-bn s kwL-S-\-I-fpsS {]kn-U v/sk{I- -dn-bpsS t]cpw H pw koepw (t\m cPn- \ -cp kwL-S-\-bpsS koepw). OR. ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN KERALA. At] Is\ F\n v t\cn dnbmw. ta d hkvXpXI ]q Wambpw icnbmsW v CXn\m Rm km ys Sp p p. ] mb v {]knU v/hm Uv sa /Iu kne . ] tI{ -/-kw- m\ Kk Uv Hm^o-k . Place ( ew) .. Date (XobXn) .. t]cpw H pw (ko klnXw). FOR OFFICE USE ONLY. Code number : .. Date of Registration : .. ID Number : .. Status : .. Chief Executive Officer/Authorised Officer NORKA - ROOTS At]- -I-cpsS {i bv v Page: 3. {]hmkn Xncn- -dn-b Im Uv ] Xn 2008 BK v apX-emWv kw m-\ v \ne-hn h -Xv. {]hmkn Xncn- -dn- b Im Uv BZy-L- - n \ne-hn hntZi cmPy- -fn D -h v am{X-amWv \ Ip -Xv. CXv {]hmkn ae-bm-fn- I v tIc-f- n Hcp Xncn -dn-b tcJ-bmbn D]-tbm-Kn- p- -tXm-sSm- w, Im Up-S-a-I v A]-I-S- -sf- p-S p- m-Ip AwK-ssh-I-ey pw A]-I-S-a-c-W- pw c p-e w cq]-hsc e`n- p C jz-d kv ]cn-c- bpw Dd- p-h-cp- p- p.}}}}}}}}}

5 K m-cns hnhn[ {]hmknt a- ] -Xn-I-fpsS ASn m-\-tc-Jbpw {]hmkn Xncn- -dn-b Im Uv BWv. CXns Imem-h[n aq v h j-am-Wv. -c-Pn-kvt{S-j ^okv 300/ cq]-. Cu ] Xn tIc-f- k m t\m hIp- ns \nb-{ -W- n-ep t\m -dq vkv hgn-bmWv \S- m- p- -Xv (C jz-d -kv ]-cn-c- C- -jz-d -kv \n-b-a- - v hn-t[-b-am-bn-cn pw). l hntZi v Bdp-am-k- n-e-[nIw tPmen-sN- p-Itbm dkn-U v s] an v t\Sn Xma-kn- p-Itbm sN p 18 hb v ]q n-bmb {]hm-kn- tI-c-fo-b v {]hmkn Xncn- -dn-b Im Un\v At]- n- mw. l At]- m-^mdw ] m-b v/ ap\n-kn- m-en n/tIm -td-j hgnbpw hnhn[ {]hm-kn- kw-L-S-\-I hgnbpw t\m bptSbpw t\m dq vkns bpw Hm^okpIfnepw epw kuP\yambn e`y-am-Wv. l kzbw km- y-s -Sp nb ]mkvt]m ns ]I v (hnk D s -sS-bp- -Xv) -A-XXv cmPy- -fn \ne-hn-ep . \nb-am-\pkr-X-amb hnk/sXmgn /Xma-k -s] an ns ]I v (DZm: kuZn. C- ma/Exit re-entry Visa ]I v), cPn-kvt{S-j ^okv 300/ cq] As - n 300/ cq]-bpsS Unam v {Um^v v (-No^v FIvkn-Iyq- ohv Hm^o-k , t\m - -dq vkv F - t]-cn AXXv taJem B m-\ v amdm-hp- Xv) klnXw ]qcn- n At]- -I At]- -It\m At]- -Is A`m-h- n IpSpw-_mw-Ktam AXXv taJem Hm^o-kn t\cnt m X]m hgntbm ka n-t - -Xm-Wv.}}}}}}}}}

6 L At]- m-^md- nse F m tImf- fpw hy -ambn ]qcn- n-t - -XmWv. A]q Whpw A]m-I-X-I D Xpamb At]- -I ]cn-K-Wn- p- -X- . l At]- m-^m-d- n ImWn- n- p hnh-c- icn-bm-sW v AXXv cmPy- -fnse C y Fw_kn As - n \m n-ep hm Uv sa / Iu kn-e , ] m-b v {]kn-U v/ ap\nkn- sNb am /tab /Kk- Uv Hm^o-k F n-h-cn Bsc- nepw km y-s -Sp- n- t]-tcm-Sp-IqSn ko ]Xn- n p H p-sh-t - -Xm-Wv. Signature of the NRK. If t^mt m ({]hm-kn-bpsS H v). (]mkvt]m v sskkv) (Black Ink). Panchayat/Municipality/Corporation in Kerala (tIcf nse District in Kerala (tIcf n GXv Pn bnemWv) ] mb v/ap\n-kn- m-en n/tIm -td-j ). 1. Name (as in passport) t]cv (]mkvt]m n D Xpt]mse). 2. Date of Birth (P\\ obXn). Day Month Year Gender M/F. Znhkw amkw h jw kv{Xo/]p-cpj . 3. Passport Number (]mkvt]m v \ ) Place of issue (\ Inb ew) Date of issue (\ Inb XobXn). Day Month Year Znhkw amkw h jw 4.}}}

7 Country of Residence (Ct m Xma-kn- p cmPyw). 5. Present Address (kztZiw) / Address for Communication (Kerala). E-mail (C sabn ) P I N. Telephone number with STD Code (t^m \ tImUv D s sS): 6. Name of Nominee with relationship (AhIminbpsS t]cpw _ hpw). Name (t]cv) Relationship (_ w) Age (hbkv). lmPcmt tcJI . 1. ]mkvt]m ns kzbw km ys Sp nb _ s t]PpI hnk t]Pv D s sS. 2. \ne-hn-ep hnk/sXmgn s] an v/Xmak s] an v ]I v 3. tdj Im Uv e`y-am-sW- n ]I v 4. ]m-kvt]m v sskkv t^mt m 2 F w 5. cPnkvt{Sj ^okv 300 cq]. Pn Ifp-w At] Ab-bvt _ -s taJemtI{ fpsS hnemkhpw NphsS sImSp- p- p Pn , taJe At] ka n-t taJemtI{ - ns A{U v Z nW taJe (Xn-cp-h-\- -]pcw) NORKA - ROOTS Regional Office Thiruvananthapuram, Kollam, Pathanamthitta Certificate Authentication Centre NORKA Centre, Thycaud (Xncp-h-\- -]p-cw, sIm w, ] -\w-Xn- ). Thiruvananthapuram Phone: 0471- 2329950.}}}}

8 E_mail: a[y taJe (G-d-Wm-Ip-fw) NORKA - ROOTS Regional Office Thrissur, Ernakulam, Palakkad, Kottayam, Certificate Authentication Centre Alappuzha, Idukki Door No. 41/1313- B, Complex (Xriq , Fd-Wm-Ip-fw, ]me- m-Sv, tIm -bw, Road , Ernakulam Phone: 0484 2371830, 2371810. Be- p-g, CSp n). e_mail: D c taJe (tIm-gn-t m-Sv) NORKA ROOTS Regional Office Kasargod, Kannur, Kozhikode, Malappuram, Wayanad Certificate Authentication Centre (Imk tIm-Sv, I q , tImgn-t m-Sv, ae- p-dw, 2nd Floor, Zamorine Squire Link Road, Kozhikkode hb-\mSv). Phone: 0495- 2304882, 2304885. e_mail: & &. t^m : +91 471 2332416, 2332452, ^m-Ivkv: +91- 471- 2326263.