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Individual/Non-institutional Group

APPLICATION FORM FOR SUBMISSION OF RECORDS


LIMCA BOOK OF RECORDS 2021

Name :
(First name) (Middle name) (Last name)
Date of Birth :
Gender :
Nationality :
Address with PIN Code :

Telephone :
Mobile :
Email :
Record Attempted :

Brief Description of Record Claim :

THE HUMAN STORY  Cinema


 Human Body (Statistical)  Communications
 Endurance & Speed (Physical)  Education
 Endurance & Speed (Mental)  Government
 Other skills related  Literature
 Collections  Media (Radio, TV, Print, Social Media)
 Medical Sciences
 SPORTS  Performing Arts (Dance, Music, Theatre)
 Science and Technology
OTHERS  Structures
 Adventure  Nature & Environment
 Agriculture  Development
 Armed Forces  Transport
 Business  Visual Arts (Painting & Photography)

Type of Record (Please tick) :

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)

Starting & Ending Time (where applicable) :


(Start) (End)
Duration :
Venue :
No. of persons involved :
Other Details :

DECLARATION
I do hereby state that all the data above are true and I am solely responsible for any error in it.

Date Signature

Verified & Authenticated by:

------------------------------------

Signature Signature
1) Name : 2) Name :
Designation : Designation :
Address : Address :

Contact No. : Contact No. :

-------------------------------------------------------------- for office use only ----------------------------------------

Documents submitted:

Photos:

Received by: on:


Action Taken: Chapter:
Remarks:

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