{]hmkn Xncn¨dnb ImÀUv

At]£m^mdw (hntZiw)
]©mb¯nsâ t]cv Cu At]£m^mdw kuP\yamWv

H¸nSm¯ IfÀ
NORKA t^mt«m ]Xn¡pI

3.5X3.5 size
A GOVERNMENT OF KERALA ENTERPRISE

(Use only Capital Letters for filling the Data sheet)

1. Name(as in passport) t]cv(]mkvt]mÀ«n DÅXpt]mse)

2. Passport Number(]mkvt]mÀ«v \¼À) Place of issue date of issue Day Month Year
(\ÂInb Øew) (\ÂInb XobXn) Znhkw amkw hÀjw

3. Address in Passport (]mkvt]mÀ«nse A{UÊv)

P I N
4. Profession (sXmgnÂ)

5. Date of Birth(P\\XobXn) Day Month Year

Znhkw amkw hÀjw
6. Address abroad (hntZis¯ hnemkw)

E-mail (CþsabnÂ)
Telephone (t^m¬)

7. Addresses in Kerala(tIcf¯nse hnemk§Ä)

I. Permanent Address in Kerala (tIcf¯nse Øncw taÂhnemkw)

Taluk (Xmeq¡v) District (Unkv{SnIvSv)

Telephone (t^m¬)
II. Present Address in Kerala (tIcf¯nse Ct¸mgs¯ taÂhnemkw)

Taluk (Xmeq¡v) District (Unkv{SnIvSv)

Telephone (t^m¬)

8. a) Duration of Overseas stay(hntZi¯v F{X Imeambn

Xmakn¡p¶p)
b) Specify the period (Imebfhv hyàam¡pI)
9. Details of Sponsor(kvt]m¬kdpsS hnhc§Ä)

NORKA-ROOTS, Top Floor, Centre Plaza, Vazhuthacaud, Thiruvananthapuram-695 014, Kerala, India
( + 91-471-2332416 2332452 Fax:+91-471-2326263, e_mail: nrkroots@asianetindia.com, URL: www.norkaroots.net, www.norka.gov.in
Contd. 2
10. Educational Qualifications(hnZym`ymk tbmKyXIÄ)

11. Family living abroad or in native place Abroad In native place

(IpSpw_w hntZit¯mtWm/kztZi¯mtWm) hntZi¯v kztZi¯v
12. Marital status (sshhmlnImhØ) Married Single Divorced

13. Religion (aXw)

14. Are you interested to join Pravasi Welfare Fund? Yes (D≠v) No(C√)
({]hmkn t£a\n[nbn¬ AwKamIm≥ XmXv]cyapt≠m?)
15. Name of Nominee with relationship(A\´cmhIminbpsS t]cpw _Ôhpw)

16. Details of family members including parents(amXm]nXm¡Ä DÄs¸sSbpÅ IpSpw_mwK§fpsS hniZhnhcw)

Name(t]cv) Relation(_Ôw) Age(hbÊv)

Declaration (kXy{]XnÚ)
I declare that the details given above are true to the best of my knowledge and belief and if anything stated is found
false legal action may be taken against me. (apIfn sImSp¯ncn¡p¶ hnhc§sfÃmw kXyamsW¶v Rm³ CXn\mÂ
km£ys¸Sp¯p¶p. Rm³ \ÂInb GsX¦nepw hnhcw sXämsW¶v t_m[ys¸«m F\nbvs¡Xnsc \nba \S]SnIÄ
kzoIcn¡mhp¶XmWv.)

Name and Signature of the Applicant/Family Member

At]£Is‚/IpSpw_mwKØns‚ t]cpw H∏pw

At]£Is\ F\nbv°v t\cn´dnbmhp∂Xpw ta¬]d™n´p≈ hkvXpXIƒ ]q¿Æambpw icnbmsW∂pw CXn\m¬

km£ys∏SpØp∂p.

Station(Øew) ........................................................................ ]©mbØv {]knU‚ns‚tbm/hm¿Uv saºdpsStbm/Iu¨knedpsStbm

t]cpw H∏pw (ko¬ klnXw)
Date(XobXn) ......................................................................

Documents to be submitted (lmPcmt°≠p∂ tcJIƒ)

1. Self attested photocopies of the relevant pages of passport including visa
(kzbw km£ys∏SpØnb ]mkvt]m¿´ns‚ _‘s∏´ t]PpIƒ˛ hnk t]Pv Dƒs∏sS)
2. Photocopy of Ration Card if available (tdj≥ Im¿Uns‚ [Ds≠¶n¬] tIm∏n )
3. Registration fee of Rs.200/- by cash or D.D. in favour of Chief Executive Officer, Norka-Roots (cPnkvt{Sj≥ ^okv 200
cq] ]Wamtbm, No^v FIvknIyp´ohv Hm^ok¿, t\m¿°m˛dq´vkv F∂ t]cn¬ FSpØ Unam‚ v {Um^v‰mtbm)

FOR OFFICE USE ONLY

Insurance Details : .....................................................

Date of Registration : .....................................................

Receipt No : .....................................................

Chief Executive Officer/Authorised Officer

Norka-Roots