Escolar Documentos
Profissional Documentos
Cultura Documentos
Name :
(First name) (Middle name) (Last name)
Date of Birth :
Gender :
Nationality :
Address with PIN Code :
Telephone :
Mobile :
Email :
Record Attempted :
Please specify quantifiability and measurability. How is the record measured and statistically validat-
ed?
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Details (measurements etc, where applicable, in cms, inches, metres:
Date of Record Attempt
(Date) (Month) (Year)
DECLARATION
I do hereby state that all the data above are true and I am solely responsible for any error in it.
Date Signature
------------------------------------
Signature Signature
1) Name : 2) Name :
Designation : Designation :
Address : Address :
Documents submitted:
Photos:
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