Application form for Aswasa kiranam - Kerala Social Security Mission

kmaqly t£a hIp¸v
(BizmkIncWw ]²Xn)
am\knI/imcocnI shñphnfnIÄ aqew AhiXbpiihsc ]cnNcn¡phÀ¡pff [\klmb¯n\pff
At]£m t^mdw
1. At]£Isâ t]cpw taðhnemkhpw :
(]cnNcn¡p BÄ)
ho«pt]cv :
ho«p \¼À, hmÀUv \¼À :
]©mb¯v/ap\nkn¸menän/tImÀ¸tdj³ :
t]mÌv Hm^okv :
Pnñ :
At]£Isâ P\\XobXnbpw hbÊpw :
kv{Xotbm ]pcpjt\m :
2. (F) ]cnNcn¡s¸Sp BfpsS t]cpw
taðhnemkhpw :
ho«pt]cv :
ho«p \¼À, hmÀUv \¼À :
]©mb¯v/ap\nkn¸menän/tImÀ¸tdj³ :
t]mÌv Hm^okv :
Pnñ :
kv{Xotbm ]pcpjt\m :
_n) ]cnNcn¡s¸Sp BfpsS
P\\XobXnbpw hbÊpw :
kn) At]£I\pambpff _Ôw :
3. ]cnNcn¡s¸Sp BÄ B{ib/_n.]n.Fð
IpSpw_¯nðs]« BÄ BtWm/Bizmk
IncWw ]²Xnb\pkcn¨pff hcpam\]cn[nbv¡
I¯pffIpSpw_mwKtamtWm ? (BsW¦nð
Bhiyvamb kÀ«n^n¡äv lmPcm¡Ww)
4. ]cnNcn¡s¸Sp BÄ am\ZÞ {]Imcapff
AhiXbpff BfmtWm? BsW¦nð F´mWv:
AhiX (tUmIvSdpsS kÀ«n^n¡äv lmPcm
¡Ww)
AsX/Añ.
5. At]£I³ Ønchcpam\apff BfmtWm?
BsW¦nð {]Xnamkhcpam\w :
kXy{]kvXmh\
At]£bnð ]dbp {]Imcw ]cnNcWw Bhiyapff
{io./{ioaXn/Ipamcn........................................................................................................................FbmÄ Fsâ
]cnNcW¯nemsWpw SnbmÄ am\knI/imcocnI shñphnfn aqew AhiXbpffbmfmsWpw
At]£bnð ]dbp hnhc§Ä ]qÀ®ambpw icnbmsWpw {]kvXmh\ sNbvXpsImffpp.
Øew :
XobXn :
At]£Isâ t]cpw H¸pw

(Hm^okv D]tbmK¯n\v am{Xw)
sF.kn.Un.Fkv. kq¸ÀsshkdpsS At\zjW dnt¸mÀ«v
{io./{ioaXn/Ipamcn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .kaÀ¸n¨
At]£bpw A\p_Ô tcJIfpw ]cntim[n¡pIbpw At]£bn³tað Bhiyamb
At\zjWw \S¯pIbpw sNbvXn«pïv. SnbmÄ BizmkIncWw ]²Xn am\ZÞ§f\pkcn¨v
B\pIqey¯n\v AÀl\mWv/AÀlbmWv. [\klmbw A\phZn¡pXn\v ip]mÀi
sNbvXpsImffpp.
Øew : H¸v :
XobXn: t]cv :
...................................................................sF.kn.Un.Fkv. t{]mPIvSv
inip hnIk\ ]²Xn Hm^okdpsS A`n{]mbw
Øew : Hm^okv ap{Z H¸v :
XobXn: t]cv :
...................................................................sF.kn.Un.Fkv. t{]mPIvSv
................................................................. .Pnñ
Hm^okv t^m¬ \¼À: ............................................................................
kmaqly kpc£m anj³ FIvknIyq«ohv UbdIvSdpsS Xocpam\wv
{io./{ioaXn/Ipamcn.......................................................................................................Fbmġv
.................................(...................................................................................................................cq]) am{Xw {]Xnamk
[\klmbw A\phZn¨ncn¡pp.
cPn. \¼À :
XobXn :
H¸v
FIvknIyq«ohv UbdIvSÀ.