F.-B.-sI.

Cjpdkv ImUv
At]m^mdw
(A\y-kwm-\ 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 in Kerala (tIcfn GXv PnbnemWv)

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

1.

Name of NRK {]hmknbpsS t]cv

2.

Date of Birth (P\\obXn)

3.

Signature of the NRK

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

Day

Month

Year

Znhkw

amkw

hjw

Gender

kv{Xo/]p-cpj

M/F

Passport/Ration Card/Election Card or any Other Valid ID Proof No.

]mkvt]mv/tdj/Ce ImtUm av AwKoIrX Xncndnb tcJbpsS \

Date of issue
(\Inb XobXn)

ID Proof submitted (\Inbnp Xncndnb tcJ)

4.

State of Residence(Xma-kn-p-\m\ kwkvYm\w)

5.

Present Address (Ctmgs hnemkw)

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)

I nominate the above person for claiming the insurance benefit, in the event of my death. ( B\p-Iq-ey- ssI-p--Xn\v apI-fn

]d-bp-- Bsf Rm \ma-\ntiw sNp-p.)

7.

Address in Kerala (tIc-f-nse tahn-em-kw)

E-mail (Csabn)
Telephone No with STD code (t^m \ tImUv DssS)
8.

Official Address (sXmgn sNp m]\ns hnemkw)

District (Pn)
9.

PIN Code(]ntImUv):

Profession (sXmgn)

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
10.

hjw

a) Duration of stay in Other State (A\ykwm\v

amkw

F{X Imeambn Xmaknpp)

11.

Other Details of Employment (sXmgn kw_amb av hnhc)

12.

Educational Qualifications

(hnZym`ymk tbmKyXI)

13.

Whether family lives with the NRK

No

Yes

(IpSpw_w {]hmkntbmsSmamtWm?)
Married

AsX

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 DESIGNATED OFFICIALS / AUTHORITY IN RESIDING STATE
The applicant has signed in my presence and he/she is living this state since ......................(month)................(year).

Name and Signature of the Official/Authority with seal

]mbv {]knU v/hmUv sa/Iukne/Fw.-F.F/Fw.-]n.-/tI{-/-kw-m\ KkUv Hm^o-k t]cpw Hpw (ko klnXw)
OR
ATTESTATION FROM DESIGNATED OFFICIALS / AUTHORITY IN KERALA
At]Is\ F\nv t\cndnbmw. tad hkvXpXI ]qWambpw icnbmsWv CXn\m Rm kmysSppp.

t]cpw Hpw (ko klnXw)

]mbv {]knU v/hmUv sa/Iukne/Fw.-F.F/Fw.-]n.-/tI{-/-kw-m\ KkUv Hm^o-k

Place (ew) ........................................................................

Date (XobXn)

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

Code number

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

Date of Registration

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

ID Number

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

Status

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

Chief Executive Officer/Authorised Officer

Norka-Roots

Page: 3

t\mmdqvkv F.-B.-sI. Cjp-dkv ImUv

Cy-bnse av kwm-\--fn Xma-kn-p/tPmen sNp ae-bm-fn-Iv tIcf km-cns t\m--dqvkv
Hcp sF.-Un. ImUv Iw Cjp-dkv ImUv ]Xn \S-m-n-h-cp-p. ImUns Imem-h[n 3 hj-am-bn-cnpw.
tbmKyX
18 hbp XnI--hcpw cv hjtam AXn IqSp-Xtem tIc-f-n\v ]pdv (C-ybvv AI-v) tPmen sNbvXph-cp--h As-n tIc-f-n\v ]pdv ncw Xma-kn-p--h. Cjz-d-kv ]-cn-c- ]-c-am-h-[n 70 h-b-ph-sc
am-{X-am-bn-cnpw
B\p-Iq-ey-
ImUv DS-abvv 2 ew cq]-bpsS A]-IS acW Cjp-dkv ]cn-c-bpw A]-I-S-n nc AwK-ssh-Ieyw
kw`-hn-m 2 ew cq]bpw `mKn-I-amb AwK-ssh-I-ey-n\v 1 ew cq]bpw e`n-p--Xm-Wv. B\p-Iq-ey- C-jzd-kv \n-b-a--v hn-t[-b-am-bn-cnpw.
At]-n-t hn[w
At]-I
- At]-t- bm-sSmw Xmsg ]d-bp tcJ-I \tI-X
- mWv.
1. At] ^okv 300 cq]. (No^v FIvkn-Iyq-ohv Hm^o-k, t\m--dqvkv F t]cn Xncp-h-\--]p-cv amdmhp Un.-Un.-bmbn \IWw.)
2. cv ]mkvt]mv sskkv t^mtm (At]--bn ]-Xn-pI)
3. tI{/kwm\ km-cns Xncn-d
- n-b tcJ/{]kvXpX tcJ-bn At]-I
- s \ne-hnse tahn-emkw Asn At]--I Cybvv AIv cp h-j-ambn tPmen/Xmakw/]T\w sNp kwm-\-nse hnemkw
sXfn-bn-p- tcJ \tI--Xp-v. (hm-S-I-No-v, hm IW- _nv, Idv_nv, sSe-t^m _nv, tdj
ImUv, ]mkvt]m tImn, t^mtm AS-p Hm^okv sF.-Un. ImUv.)

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)

1.

Name of NRK {]hmknbpsS t]cv

2.

Date of Birth (P\\obXn)

3.

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

Day

Month

Year

Znhkw

amkw

hjw

Gender

kv{Xo/]p-cpj

Present Address (Ctmgs hnemkw)

STATE
P

E-mail (Csabn)

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

4.

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

Name (t]cv)

Relationship (_w)

Age (hbkv)

M/F

Page: 4

]qcn-n At] ^okv Bh-iy-amb tcJ-I Fnh klnXw Xmsg-]-d-bp t\m--dq-vkns Hm^o-kp-I-fn
kan-t-X
- m-Wv.
1.
2.
3.
4.
5.
6.
7.
8.

t\m--dq-vkv, doP-W Hm^o-kv, ^v ^vtfm, t\m sk, Xncp-h-\--]p-cw,

t^m0471 2329950
t\m--dq-vkv, doP-W Hm^o-kv, hn.-Fw. tImw-Ivkv, kn.-]n. D tdmUv, Fd-Wm-Ipfw.
t^m0484 2371830, 2371810
t\m--dq-vkv, doP-W Hm^o-kv, sk v ^vtfm, kmtam-dn kvIzb, enn tdmUv,
tImgn-tmSv t^m0495 2304882, 2304885
F.-B.-sI. Uh-e-]vsa v Hm^o-kv, {SmhIq lukv, sI.-Pn. aKv, \yq Uln 110001
t^m01123384369
F.-B.-sI. Uh-e-]vsa v Hm^o-kv, tmv \w.8. ,sk-Iv 30 F, tIcf lukv, hmin,
apws_400703 t^m022 27812129
t\m--dqvkv kmvssev Hm^o-kv, sk v ^vtfm, kmbn _nUnw-Kv, satm-Snv
Nn\v FXnh-iw, s^-lvKp-\n, _tdm-U390002, t^m0265 2389885/2750560
t\m--dqvkv kmvssev Hm^o-kv, B/17, 15 kv{Sov, Am \K, sNs600040,
t^m044 26212060
t\m--dqvkv kmvssev Hm^o-kv, {io\mcm-bW kanXn _nUnwKv \1,
Dkq, Smv tdmUv, _mwq, t^m080 25305090

ImUv hnX-cWw
At] kan-p Hm^o-kn\npw Cjp-dkv ImUv hnX-cWw sNp-X
- m-Wv. t\m-d
- q-vkns Hm^o-kpI Cm e--fn \npw X]m amKw t\m--dqvkv slUv Hm^o-kn-tebvv At]--I Ab-bvp--h-cpsS
Cjp-dkv ImUp-I Ah-cpsS tIc-f-nse hnem-k-n ]d-n-cn-p Pn-bnse t\m skv, av kwm-\-fnse ae-bmfn s^U-td-j, t\m--dqvkv cPn-tUv Atkm-kn-tb-j hgntbm hnX-cWw sNp--Xm-Wv. At]-It\m Ah-cpsS {]Xn-\n-[ntm ImUv ssI-m-hp--Xm-Wv.

kpc-n-X-amb hntZ-i-sXm-gn-en\v

tPm_vkv t\m
cPn- sNq www.jobsnorka.gov.in

hntZ-iv Hcp tPmen F kz]v\w bmYmy-am-hs !

hymP dn{Iq-nwKv GPp-am-cpsS NXn-bnsSmsX PohnXw `{Z-amIq!

18004253939 (tSm {^o) hntZ-i-p-\npw 091 471 2333339 hnfn-q........

t\m-d
- qvkv
t\m sk, ssXm-Sv, Xncp-h-\--]p-cw365014
t^m +91 471 2332415, 2322452, ^mIvkv : 2326263
Csa-bn mail@norkaroots.net sh_vsskv www.norkaroots.net