{]hmkn Xncndnb ImUv

At]m^mdw (hntZ-i a-e-bmfn)

At]m^mdw kuP\yamWv

If t^mtm
(]mkvt]mv sskkv)

(Please read the guidelines before filling up the application. Use only CAPITAL Letters)
(At] ]qcn-n-p--Xn\v ap]v \n_--\-I hmbnp-I. Cwojv henb A-cn
]qcnn-p-I)
District (Pn)

Signature of the NRK

Panchayat/Municipality/Corporation
(]mbv/ap\n-kn-m-enn/tIm-td-j)

({]hm-kn-bpsS Hv)
(Black Ink)

1.

Name (as in passport) t]cv (]mkvt]mn DXpt]mse)

2.

Date of Birth (P\\obXn)

3.

4.

Day

Month

Year

Gender

Znhkw

amkw

hjw

kv{Xo/]p-cpj

Passport Number (]mkvt]mv \)

Place of issue (\Inb ew)

M/F

Date of issue (\Inb XobXn)

Day

Month

Year

Znhkw

amkw

hjw

Country of Residence

(Ctm Xma-kn-p cmPyw)

5.

Address for communication (I-b-bvp--Xn-\p hnemkw) (kztZ-iw)

E-mail (Csabn)
Telephone No with ISD code (t^m \ tImUv DssS)
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-\ntiw sNp-p.)

Name (t]cv)

7.

Address abroad (hntZis hnemkw)

8.

Address in Passport (]mkvt]mnse hnemkw)

Relationship (_w)

District (Pn)
9.

Profession (sXmgn)

10.

a) Duration of overseas stay (hntZiv F{X Imeambn

Xmaknpp)

Age (hbkv)

PIN Code(]ntImUv) :

hjw

amkw

NORKA-ROOTS, NORKA Centre, Thycaud, Thiruvananthapuram-695 014, Kerala, India

( + 91-471-2332416, 2332452 Fax:+91-471-2326263, e_mail: mail@norkaroots.net, URL: www.norkaroots.net, www.norka.gov.in

Page: 2
11.

Details of Sponsor (kvt]mkdpsS hnhc)

12.

Educational Qualifications

(hnZym`ymk tbmKyXI)

13.

Whether family lives abroad or in native place

In native place

Abroad

(IpSpw_w hntZitmtWm kztZimtWm)

Married

hntZiv

kztZiv

Single

Divorced

14.

Marital status (sshhmlnImh)

15.

Religion (aXw)

16.

Details of family members including parents (amXm]nXm DssS IpSpw_mwKfpsS hniZhnhcw)

Name (t]cv)

Relationship (_w)

Age (hbv)

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 sImSpncnp hnhcsfmw Fs Adn-hns-n-S-tmfw kXyamsWv Rm CXn\m kmysSppp.

GsXnepw hnhcw sXmsWv t_m[ysm F\nsXnsc \nba \S]SnI kzoIcnmhpXmWv.)

Name and Signature of the Applicant/*Family Member

At]Is/IpSpw_mwKns t]cpw Hpw

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)................(year).

Name and Signature of the Embassy/Consulate Official with seal

OR
t\m dqvkns AwKo-IrX ]n-I-bns kwL-S-\-I-fpsS {]kn-U v/sk{I--dn-bpsS t]cpw Hpw koepw (t\m cPn \-cp kwL-S-\-bpsS koepw)
OR
ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN KERALA
At]Is\ F\nv t\cndnbmw. tad hkvXpXI ]qWambpw icnbmsWv CXn\m Rm kmysSppp.
]mbv {]knU v/hmUv sa/Iukne/Fw.-F.F/Fw.-]n.-/tI{-/-kw-m\ KkUv Hm^o-k
Place (ew) ...........................................................................
Date (XobXn)

t]cpw Hpw (ko klnXw)

........................................................................
FOR OFFICE USE ONLY

Code number

: .............................................................

Date of Registration

: .............................................................

ID Number

: .............................................................

Status

: .............................................................
Chief Executive Officer/Authorised Officer

Norka-Roots

Page: 3

At]--I-cpsS {ibvv

{]hmkn Xncn--dn-b ImUv ]Xn 2008 BKv apX-emWv kwm-\v \ne-hn h-Xv. {]hmkn Xncn--dnb ImUv BZy-L--n \ne-hn hntZi cmPy--fn D-hv am{X-amWv \Ip-Xv. CXv {]hmkn ae-bm-fnIv tIc-f-n Hcp Xncn-dn-b tcJ-bmbn D]-tbm-Kn-p--tXm-sSm-w, ImUp-S-a-Iv A]-I-S--sf-p-Spm-Ip AwK-ssh-I-eypw A]-I-S-a-c-W-pw cp-ew cq]-hsc e`n-p Cjz-dkv ]cn-c-bpw
Dd-p-h-cp-p-p. km-cns hnhn[ {]hmknta- ]-Xn-I-fpsS ASnm-\-tc-Jbpw {]hmkn Xncn--dn-b ImUv
BWv. CXns Imem-h[n aqv hj-am-Wv. -c-Pn-kvt{S-j ^okv 300/ cq]-. Cu ]Xn tIc-f- km t\m hIpns \nb-{-W-n-ep t\m-dqvkv hgn-bmWv \S-m-p--Xv (Cjz-d-kv ]-cn-c- C--jz-d-kv \n-b-a-v hn-t[-b-am-bn-cnpw).
l

hntZiv Bdp-am-k-n-e-[nIw tPmen-sN-p-Itbm dkn-U v s]anv t\Sn Xma-kn-p-Itbm sNp 18 hbv

]qn-bmb {]hm-kn- tI-c-fo-bv {]hmkn Xncn--dn-b ImUn\v At]-n-mw.

At]-m-^mdw ]m-bv/ ap\n-kn-m-enn/tIm-td-j hgnbpw hnhn[ {]hm-kn- kw-L-S-\-I hgnbpw

t\mbptSbpw t\mdqvknsbpw Hm^okpIfnepw www.norkaroots.net epw kuP\yambn e`y-am-Wv.
kzbw km-y-s-Spnb ]mkvt]mns ]Iv (hnk Ds-sS-bp--Xv) -A-XXv cmPy--fn \ne-hn-ep
\nb-am-\pkr-X-amb hnk/sXmgn/Xma-k -s]anns ]Iv (DZm: kuZn. C-ma/Exit re-entry Visa ]Iv),
cPn-kvt{S-j ^okv 300/ cq] As-n 300/ cq]-bpsS Unam v {Um^vv (-No^v FIvkn-Iyq-ohv Hm^o-k,
t\m--dqvkv F- t]-cn AXXv taJem Bm-\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\cntm X]m hgntbm
kan-t--Xm-Wv.

At]-m-^md-nse Fm tImf-fpw hy-ambn ]qcn-n-t--XmWv. A]qWhpw A]m-I-X-I DXpamb

At]--I ]cn-K-Wn-p--X-.

At]-m-^m-d-n ImWn-n-p hnh-c- icn-bm-sWv AXXv cmPy--fnse Cy Fw_kn Asn \mn-ep hmUv sa/ Iukn-e, ]m-bv {]kn-U v/ ap\nkn- sNbam/tab/Kk-Uv
Hm^o-k Fn-h-cn Bsc-nepw kmy-s-Sp-n- t]-tcm-Sp-IqSn ko ]Xn-np Hp-sh-t--Xm-Wv.

Signature of the NRK

If t^mtm
(]mkvt]mv sskkv)

({]hm-kn-bpsS Hv)
(Black Ink)

Panchayat/Municipality/Corporation in Kerala (tIcfnse

District in Kerala (tIcfn GXv PnbnemWv)

]mbv/ap\n-kn-m-enn/tIm-td-j)

1.

Name (as in passport) t]cv (]mkvt]mn DXpt]mse)

2.

Date of Birth (P\\obXn)

3.

4.

Day

Month

Year

Znhkw

amkw

hjw

Passport Number (]mkvt]mv \)

Place of issue (\Inb ew)

Gender

kv{Xo/]p-cpj
Date of issue (\Inb XobXn)

Day

Month

Year

Znhkw

amkw

hjw

Country of Residence

(Ctm Xma-kn-p cmPyw)

5.

Present Address (kztZiw) / Address for Communication (Kerala)

E-mail (Csabn)

Telephone number with STD Code (t^m \ tImUv DssS):

6.

Name of Nominee with relationship (AhIminbpsS t]cpw _hpw)

Name (t]cv)

Relationship (_w)

Age (hbkv)

M/F

lmPcmt tcJI
1. ]mkvt]mns kzbw kmysSpnb _s t]PpI hnk t]Pv DssS
2. \ne-hn-ep hnk/sXmgn s]anv/Xmak s]anv ]Iv
3. tdj ImUv e`y-am-sW-n ]Iv
4. ]m-kvt]mv sskkv t^mtm 2 Fw
5. cPnkvt{Sj ^okv 300 cq]
PnIfp-w At] Ab-bvt _-s taJemtI{fpsS hnemkhpw NphsS sImSp-p-p
Pn, taJe
ZnW taJe (Xn-cp-h-\--]pcw)
Thiruvananthapuram, Kollam, Pathanamthitta

(Xncp-h-\--]p-cw, sImw, ]-\w-Xn-)

a[y taJe (G-d-Wm-Ip-fw)

Thrissur, Ernakulam, Palakkad, Kottayam,
Alappuzha, Idukki

(Xriq, Fd-Wm-Ip-fw, ]me-m-Sv, tIm-bw,

Be-p-g, CSpn)

Dc taJe (tIm-gn-tm-Sv)
Kasargod, Kannur, Kozhikode, Malappuram, Wayanad

(ImktIm-Sv, Iq, tImgn-tm-Sv, ae-p-dw,

hb-\mSv)

At] kan-t taJemtI{-ns A{Uv

Norka- Roots Regional Office
Certificate Authentication Centre
NORKA Centre, Thycaud
Thiruvananthapuram
Phone: 0471- 2329950
e_mail: idcelltvm@norkaroots.net
Norka- Roots Regional Office
Certificate Authentication Centre
Door No. 41/1313- B, V.M Complex
C.P.Ummer Road , Ernakulam
Phone: 0484 2371830, 2371810
e_mail: idcellekm@norkaroots.net
Norka Roots Regional Office
Certificate Authentication Centre
2nd Floor, Zamorine Squire
Link Road, Kozhikkode
Phone: 0495- 2304882, 2304885
e_mail: idcellclt@norkaroots.net

&

&

t^m: +914712332416, 2332452, ^m-Ivkv: +91-471-2326263