IF No.1011AledIILieI~ !i~a;a ~r.T (;ilmm) f.l~2!l!"! fife Jnsuronce <Lorporation (Nepal) Ctd. , (A Joint Venture of Life Insurance Corporation of India)

~~~ lOl""lI\"t<ll'll ~ it-f, ~o'(~ ~ m ~ aft;rr ~, ~o)'q, ~;;fiq;f of!llT ~ 1J'f ~~)

(Registered with Nepal Gov!. under Company Act 2053 & received permit for life insurance business as per Insurance Act 2049)

JftdCJ1 iIt<JtT p'«I

mT<f~ I'{TTh,"TfProposal No. Branch

~'l111: tfi1i'rAgent's Name: Photo ~-;f. Ifilm:Code No. Date:

Id wh{dt LIFE INSURANCE PROPOSAL FORM

(~ ~~ .q1§'14b I '3'm VTWIT fu;t m rrn~ t'1ID. ~ <IT ~ ~ f<t;f~t f~~ ~~ lTWr ~ I),,'" .., ~..:lo

(All answers to be filled in legibly. Answers must be given in words. Strokes of the pen or dots or dashes will not be accepted as replies.)

9 1

name first) !U 'ftl1 (~ ~) / Full Name (Sur

~

English

Q"lI"iH4i1 rom ~

~ ~ / Permanent Address

~ 'inIT1lT ~

;;plf f1lfu f'q.ll".

Date of Birth t.ll". / AD

~~I\{4i1 ~

\l~l\{a>t ~

~~It:t4i1 ~ ~ "1ll1

If Nominee is a Minor

aftm ~ "1ll1/ Plan of Insurance

'H~)

2 (a)

~.(19)

2 (b)

, ­

4t;r;r m-r /Plan No

3l'Cl'fir /Term: qq /Years

~ 1f,f ~* /Mode of Payment* ~ I ~/~ /If!fuq; Yearly/Half Yearly/Quaterly/Monthly

~~

Place of Birth

uf~ I*~: 'q'./Bfi* ...Nationality Sex: M / F

~ it!(lf Object of Insurance/Address for communication

~~~~ ; f~.tr.tt <m-$) Your Telephone Nos details (witll STD Code)

(q;)~ (a) Offic;e

(\9)~ (b) Resldenco

(Tfl "i~i<f ic) Mobile \U') s-",,;, (d) E-m,lIl

fcrcr\uT / Nature of age-proof SUbmitted \3ln' Age __ crt /Yem __ llft;-rr / Month __ ~ / Day

W I~ ;)jrLiR'1Lill/Age(NearerBirthday)' __ crt /Year

I B.S. DODD DD DO ~ m 'ftl1 (~ ~) / Father's Full Name (Surname first)

DDDD 00 DO tfTftrcr l: ~vc4l\{q;1 oqfu; ft'r"'f'ir 1T<fT / Relation between LA & Nominee !U 'fll1 / Nominee's Full Name ~/Age

00'lfi tm;:rr / Nominee's Permanent Address

~ / Nominee's Father's Full Name

~ '\ ~'VJiI\{4,1 ~ ~ -:mrr Appointee's Full Name and Address

~~~~~~~l{7TTfflir~ ~/Age Relation between Appointee and Nominee

~~~~~~ Signature of Appointee as token of Consent

;;n:iIT lT1q;T ~~cB~~~. Amount Deposited Sum Assured Rs. ~ 'SlT"{t'I1 <R ~

~ ?fl1ft;~1~ BTl1cfiT ~1i:l94'MI ~? ~/*" * Wr ~.If Policy is to be dated Is Accidental Benefit required? Yes/No Rs.back. indicate date. ~ t1N cfiml ~. Accidental Benefit Sum Assured Rs. f1Ifu

Date*Clf <I\l:s<a>t 3l1i:l~4C'fl(11 ~?* ~/~ Is Term Rider required ?* Yes/No

~-;f.Clf ~~ etllITf ~. Receipt No. Tp.rm Rider Slim Assured Rs.

I

I ~ m I Present Occupation ~~~ vq;fu I Exact nature of Duties ~ <

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~ O\itlu64it ~~~ ? Length of Service with Current Employer

I

~ liTn«rr

m OOR ~ ifllf "{ ~ I Name & Address of present Employer

~~~. "$~~GffiT~?JtI&<I'114it ~ I Source of Income Your Educational Qualification Annual Income Rs. Are you an Income Tax assessee?

~tr'lfol, ~ ~;f. ~~l If yes. state your PAN.

~~~~~ ~~~~~ fcfcrorr ~ II If you are Employed in the Armed Forces, Please fill out the details below.

~ 1J'VT I ~ \itT fuo ~~~~~ "$~~~({'Firr~~~7~l~l ~~~fuftr Medical Category after Medical Rank therein Date of Last Medical Examination ~~~~?~~~l Examination Were you ever below A-1 Category? If so, when?Wing to which you belong

cf; ~~~~~ eftm~. ~~ mrq lf1 ~~ ? ~~ ~ fcfcrorr ~ I Have you ever proposed for your life assurance to any other insurer? If Yes. give details including terrflS of acceptance.

I

~ lnf ~~ ;;ffcR <llJlI~€l6~"'1 ~ ~, Please give details of alilhe poliCIes or1 your iiII' (other than thiS proposal)

I c1; ~ Tfr 3f¥R ~~'!R.~~~~ ~ ~~ ~~~,afnn<t,l ~ ofim iW ~~~m'tTR"UT i(OO ~ merr~.err~~~;f. ~ifllf fclq~~if'<rr 3TWI ~ ~~? err ~ [l{fu~~? With ~ fGr;rr<rt If not. Policy No. Short Name of Insurer Insurance Type & Sum Assured Is the Policy If not, give due date ofAcc.epted at Accidental With Medical Year of give dt:lails last premium paid or Term Ordinary Rate Inforce?Benefit or not

I or notIssue date of surrenderas proposed ?

I I I I I

. .

~ . ~~ (frif ~ 3fClfum ~~ cfrlIT ~~~ ~ 'U ~ .(llil(;\€llil 1:!f{qf~ ~ ~ 'lR 4'qn.41'1~ ~ qf.f 'PIT mrcf ~~~ I te . Corporation does not entertall1 any fresh proposal for Insurilnce where a policy has lapsed or has !:Jeen converted Into paid up policy with in the last 3 years.

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1;;. cl; ~ :;;ffcr-:r cft+rrcI;T ~~~ 'f,q.,"lill ~~ ~ cA iRT ~/lm1:r ~~:ru~~ Has a proposal on your life made to any company, ever been .. ~ If yes, give details. Yes/No8.

('if) ftf;aT ~ f1rlfr, ~ err ~~ f1rlfr ? (a) Withdrawn, Defe~red, Dropped or Decfined ?

(~)~~m~~f1rlfr? (b) Accepted with extra premium or lien?

(If) wrcfuf mt ~ lfl{q; -u*rr ~~ f1rlfr ? (c) Accepted on terms other than those proposed?

iifrfc«:r / LI 'ling ~ /Expired ~. qif(cllf<'f sftnmr

Family History ~ f'4lfUl <¥I fMo ~~~ ~ q;rorr9. Age State of Health Age at Death Cause of Death

"CfTi! / Father

amrr /Mother

GT\i!/~ Brothers

iifrfc«:r m§Ql living

¥~JDead

fWt /~ / Sisters

iifrfc«:r ~ JLIVIng

¥~ Dead

~ /'qfu / Wife / Husband

Wu J~ I Children

~mm/Li'llng

+rn~. Dead

~ '::'T' <IT l~' I m- ""RT '~' ..r.r :\j ~ ".:I,

~ ~~i~l"1 I9°. ~~::..,i·., I 10

""~I IPersona' ~Is:~r: Answer 'Ves' or 'No' If yes please give hili details I

'if. ~~ fcnTo 1:ffq ~ cB UlT ffilfi ~~~ crrtt ~ \3q"'ll {em I 3lICl94<f.i11 ~ f<ni'r, ~ F.::(ra;i"q~*1 ~ ~ ~ ~ -; I

a DUring last five years did you ever consult a medical practioner for any ailment I r'lQur,ng trt:a:~1en; :OJ mo'e 'har -: ';cek .' ! ~ .~. f~ ~ ~~Fc ~ ;g. 'if ~ • n ~.~, ·~I .....p~lq>ffil err .; ~ l"l <tictll'fj <=i"T11T

-¥ ~<IT~mr<n+IT~fl~~? b Have you ever been admitted to any hospital or nursing home for general check up,

observation treatment or operation?

If. <l; ~ fcf1ffi ~ <ri ~ "4 II'Ul cil ~ Cfil41i"14ill 3l'iqft4i1 fl ~~ ? c. Have you remained absent from place of work on groundsof health dUring last 5 years?

~. <l; ~ ~, ?te, ~ ~, ~, llfurr;q; <IT RrII ~~ <F trrcnc tflmr ~ a:r ~~ ?

d. Are you sufferting from or have you ever suffered from ailments pertaining to liver. stomach, heart. lungs. kidney. brain or nervous system?

~. <f; ~ ~, wRrr, ~ a:r f¥;; ~, ;p.fRf{, Wt Ulf, ~,

l'i1$(lru~, ~, a:r ~ ~~~~ a:r ~~ ? e. Are you sufferting from or have you ever suffered from Diabetes, TUberculosis, High

B.P., Cancer. Epilepsy, Hernia. Hydrocele. Leprosy or any other disease?

i:f. <f; ~ mtfut; iif"lIik'il ~ 1c a:r ~~ ? f Did you ever have any bodily defect or deformity?

~. cl; ~ (9) '{iRfi, (~) ~ m. (~) ~~~ ('a') c¥ ~

~~mlf1~a:r1T1~~? g. Do you use or have you ever used (1) A/chollc drinks (2) Drugs (3) Narcotics

(4) Tobacco in any forms

\Jf. cl; ~ ~qlC!I$fl*l <fi a:r ~ ~cft c¥ ~ \3"Cf'i'.l'IT <r1 ~~ a:r ~ ~~~? 3NCfT~~c¥;;Wqlf{Fij ~~?

h. Have you ever required or are at present availing/undergoing medical advice. treatment or tests In connection with Hepatetls B or AIDS related condition.

1fi. <f; ~ mrcf tfiRlf ~~~~ '{ mt mrt't ~~ ~ ? i. Have you understood fully the terms & conditions of the plan you propose to take?

<ffi1 f'q;.1JT.99. f,;jFq;~~mfll 3f~l';<'.ff:.ad ~ 3lT1f'iT tlci; m (~,lfi.lIT) \ <ffi1 (#;.ilfi.lfTl ~tm{ I m ~.lft. 11. In non-medical cases, please state exact height in ems. & weight In kgs. Weight kgsHeight ems

+l~\1I"') \1l'flr ~ I For Female Lives Only

9~.(q;) <f; ~~~~ ~ ? err ~ji"4~lIl1U (I ~ +i~'1I'lIt'l$) fufcrcf;m~~? ~~~ 12. (a) Are you pregnant now? ~flria"~1 ~S1~~?~'lfo't~~1 ~I

Date of last mensturation section? If so, give details

Date of last delivery. Have you had any abortion or miscarriage or ceasarian

~ClWfq;~~ l{U;;n:r9~.(~) ~~ Husband's annual income Husband's Full Name Husband's Occupation 12. (~

~ ;;fiq;; eth:mfrr 'tl':OlP,t.!'d ~~ I Detail::; of his Life Insurance Policies.

9~.(lf) "l')+il~@q>j ~ ~ 12. (c) ~;r, ~;;n:r ~ vcm:: \ 3l"C'Ifu

('<ffij; err ~)Policy No. Insurer's Name Sum Assured Table & Term Present status ofthe policyIf'

~

111.1

i _. ~

9~. <f; m1fcrcr ~~ \ mfq;r Gl'itlfT ~~ CfVl;r lJtq;T ~ ? ~tWr 13. Has your Agent described the RUles and Regulations about your plan of insurance? Yes/No

9¥. ~~~~ (~!/TiiGlTC:~~~ ~l 14. Bank Account details to receive payment from Company.

("iP) ~~~ : GR«f @TdT / ~ @TdT

(a) TYP8 of Account : Saving I Current

(~) ~ lim rn<r{

(b) Account No.

(<T) ~ lim ~~ rrn:r \ ~ : (c) Name &Address of the Bank where you have your Account: _

11 ;;romr eN \lft<r;:r ~ mflT 1I«iJCf ~ ~, <IT

~~f'q;~~\~AA~mrtt~~~\~~~~tNT~fcr<roJTTTWL\AA~~~

~ mlt "l'1+i4>~I{ ~ qf.:r ~ lTmf rct"HUli\(CI m ~ ~~~ 111 ~~~ ~ \ 'Ei'rfurr ~ f'q; rft ~,

~ tNT ~~~ rct'l(Oj4>1 4>jlj\1lIM{i ~ \' ~ ~0'fll1~"'8 i';Qlhl'1 (~) ~.~~ amm: ~ \ ~~ cB 3fm=tT ~~ crm lfffiT ~~ rrtt oft+i4>~I{ "fCf4I~C?;q>j ~ rft q;m: 'iuf(CIq+i1 ~~ \' ~~~~~

aft+i4>~j{j ~~ I

~~ '4>l'¥, tftr-~, "tf(Of'1' err q(+=q(l~ lfGf <B ~Fq;ffi4» ~ qr :(I\1I.II«:ldI~I{ lnq .."'illdl$) 3fIm<lIT ;;fiq;; ~ t11flr vmR ~~~ err ~~ <B ~~ Uq; ~111~C?;q,') ~ '1f.:r oMrd' ~~~, ~,

'il'fur err ~~ arlffi err ~~ fmf "l'1fl:1MlI{ 1RA' ~ c()+iIJl@$) Cf'mln ~~,~~ ~ l:lf.f ~ ~ ~"f4l~"'8

itl4'f<:tI'1 (~) ft:f. ~ ~~~ I

~ ffi ~ f1:Ifu ~ CNT ~ aft+il~l("4>q,l ~ ;;rr{t ~3l<TT'tt (9) ~ ifunrr ¥ ~~ err mr zrrf4q; ~

err mI"/mI" qf'<ClI<4>j <B ~ ~j~+il <B ~~~~ qr ~~ ~ ~~ {IN ~~ err ~ mf lRT 3R mtq;r ~ $0 'i1"C?;+rT 11 ~~~ 'i'1f);f'tlI( lf1'tA' 'i1"C?;+rT mlfYfq;r ~~~ ~~~ I m m;rr{ lIT

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"Answers to Question are given after reading the questions carefully"

Declaration by the Proposer

the person whose life Is herein being proposed to be assured. do hereby declare that the foregoing statements and answers have been give by me after fully understanding the Questions and the same are true and complete in every particularand that I have not withheld any Information and I do hereby agree and declare that these statements and this declaration shall be the basis of the contract of assurance between me and Lie (Nepal) and that if any untrue averment be contained herein, the said contract shall be absolutely null and void.

Not withstanding the provision of any law. sage. custom or convention for the time being inforce probihlting any doctor, hospital andlor employer from divulging and knowledge or Information about me concerning my health or employment on the grounds of secrecy, limy heirs, executors. administratiors and assigness or any other person or persons haVing interest of any kind whatsoever in the policy contract issued to me hereby agree that such authority. having such knOWledge or information, shall at any time be at liberty to divUlge any such knowledge or information to the company.

And' fu.rther agree that if after the date of submission of the proposal but before the Issue of F. P. receipt (1) any change in my occupation or any adverse circumstances connection with my financial position or the general health of myself or that of any members of my family occurs. (2) if a proposal for assurance or an application for revival of a policy on my life made to any insurance company or any office of this company has been withdrawn or dropped. deffered or accepted at an increased premium or subject to a lien or on terms other than as proposed, I shall forthwith Intimate the same to the company.

~ I Date: ~ I Year lih I Month __ rra- I Day__~:_--------------Place:

maflcl;T ~ : --------- ­Signature of Witness :

~ 'ITl1 . ----------- ­Name of W loess ­

~fIrir irm : ----------- ­Occupation of Witness:

~ ~. ---------- ­Address of Witness:

~ rrrfu 1ffiITcf rR' ~~ en 3itor wr (NT ~ 'tU ';fJlf Signature or thumb Impression of the person whose life is proposed to be assured

~ mfti ~ 9~'1e:li~) ~ ~ ~ ~ ~~, l{Tfq ~ V~ ~ 'Ullt ~~ § AA. ~~~

lf1~1 If the above declara on is signed in any language other than the languages in which if is printed then the person withnessing the signature must also fill the declaration below

~ ./1. liT ~~ If.f oqffi;\{1 <I lTft.r ~ I I This should be done by the person who fill up declaration form.

II liT ~~ fq; ~ ~ 9«1lqcti<i1l~ UlIfr ~~ \ ~~~~~~ ~ I I hereby declare that I have fully explained the above questions to the proposer in hislher language &have truthfully recorded the answers given by the proposer.

~ lJ'1 ~ ';fJlf '{ ~ I Declarant's Name and Address:

~ I Signature

7/.../2. ~~ ffim ~ lin case proposer is illetrate.

ctiqlnl'1f{ll ~~ <¥ qqf{filij ~ oqffi;iillc Y@Cjcti¢) aITor wr ~~~ I His/Her thumb impression should be attested by a person of standing whose identity is unconnected with the company & the following declaration should be made by him

"ll ?:iT "EfrtroTI ~ fq; ~ Y@ClCfl<i1I$ 1ffiITcf 'If'fCfiT ~~ 3!'f ('qT'qT) +IT ~~ " ~@qctiJl \llrtT ~ llT"f

'Il"«1R ~ aITor wr ~ tit I" "I hereby declare that I have fully explained the questions & contents of the proposal form to the proposer in language & that the proposer has affixed the thumb Impression above after fully understanding the contents thereof."

~ ~~ ';fJlf \ ~ I Declarant's Name and Address:

~$CJ'T I t!": ........."'., ..-.

FORM FOR ABSOLUTE ASSIGNMENT OF POLICY

I '" in consideration of the sum of

Rs paid to me by the receipt

of which I hereby acknowledge. do hereby as beneficial owner assign(s) to the said ..

its executors. Administrator(s) and assign(s) the policy of assurance on the life of myself granted to me by LIFE INSURANCE

CORPORATION (NEPAL) LTD. assuring the sum of Rs....................................................... ..And No. .

and b~arjng date the day of .. ....... and Sum Assured thereby

and all other moneys, benefits and advantages to be received there under.

Dated at this day of .

Witness:

Signature:

Full Name:

Address: Signature of Life Assured

ASSIGNMENT NOTICE TO THE COMPANY

LIFE INSURANCE CORPORATION (NEPAL) LTD. Place

G.PO. Box 21905, Naxal, Kathmandu Date ..

Dear Sir,

Re: Life Assurance Policy No.............. ...

I hereby give you notice" that I have assigned the above Policy to ..

on Please acknOWledge the receipt of this notice and forward the enclosed policylDeed of

Assignment to after registering the Assignment thereon in your ledger.

Certified that the thumb impression herein Is that of

.......................................... who admit haVing affixed the

same after understanding the contents hereof.

Witness: Yours Faithfully,

Signature

Name: .. SignaturelThumb impression ofAssignor

IF. No.1021AglLICI~ s.«iQ.,. ~~ (~)~ . -' Cife Jnsuronce <IorporQtion (Ne,PQ() Ctd.

~~ r (A Joint Venture of Life Insurance Corporation of India) Proposal No.

('ittfri;r If\<m ~ "'~I\1'1"'1 q;p:r;fi~, ~o~~ ~ ;raf \l't <f\lrr t-f, ~o¥,\ ~ ~ <f\lrr ~ 1fif ~~) lllffiCf m ~ mID

Branch where proposal Is submitted (Registered with Nepal Gov!. under Company Act 2053 & received permit

for life insurance business as per Insurance Act 2049)

3lf~<tiHf~1 ~ \Affia~"1~ :i\f@+i \Affia~"1

Agent's Confidential Report/Moral Hazard Report

3lf~ om::r .. ;-trr;n : ~~ Agent's Name & Address: Code No.

1ffiif ~ fu<mrr : Club Membership particulars:

\IRli Cl <4'''';' om::r Proposers Name

~om::r

~

Age

~

~~ Proposed S. A.

9R1ia,.;",1 itm ~

I ~ ~

Name Age Proposer's Occupation & nature of work

~.1 q; a ~ S1!'iiI<l(f;t1I~ (f;~~~~ ~ ~ ? Since how long do you know the Life Assured?

<n. a.

(g. cf; ~ SH'1lilCfi<m rnam ~ ? ~ ~ ~ ~ ~ I ~.

b. Are you related to him/her? If so, give details of relationship. b.

If. IJ@Clifi'1>l ~ ~ q;fu ~ ? If. c Educational qualifications of the proposer? c.

~.2. (j) 'll«lIClCfic61 errfltq; ~ ~ ~ 1 q;. ~. (I) Given details of his/her Annual Income from: a. Rs.

q;. ~ a.

~.

Employment

exmrJ1.iJirnT

l!f. b.

~. Rs.

b. Business/Profession 'T. ~.

'T. 3fi'li m rru ~ ~ Il c. Rs.

c Other sources (Specify details)

~~. / Total Rs.

(ii) ~~~~~~'r1~~? (ii) What proof of income was verified by you In respect of Income stated above? 1------------------- ­q; if; l(r ~ t:flrof it, ~ it ~ ()\iI'Ii<~IClI~ ~ (ffi"l' ~ lT1 ~~ ? a. Is salary sheet or certificate Issued by the employer?

~. cl; m:qrft ~a;I'3Ulr2ml ~.'ll1fllT tf.I' tr ? tr 'iR 3{flfc1j\ ~~

~~~(PAN)~~l b. Whether it Is certificate Issued by CA ? What is the PAN alloted by IT

authorities?

1T of; ~~ qfuM 1Jlnflmr ~~ ? ~ 'iR ~~ iftGR: (PAN)

~~I c. Whether copies of Income tax retums verified? What is the PAN?

~ m oqfu:;mr ~ Y@il<t>il>'1 f'cffim ~ vfu ~~ ? ~ ~ 3l'1t1T'{liT ~ 1Jffi1CT ~~ i

Are you personally satisfied with the financial standing of the proposer & justify the current proposal.

~.3. q;. ~ ijlilj""ldl11 ~~~ ~ ? a. What is the general state of health of the life proposed?

ij'. cf; ofifmr amf, ~ a;m, Cfi11 ~, mt1ftl; ~~ err ~~ ~~7

b. Does he/she have any physical deformity. impaired sight or hearing, physical impairment of mental retardation?

'T. cf; ~ iill'l¢lft+l1 afli'lffi ~~ tftmr ~~ ? err ~~ ~? err~31~ctl{'jql ~~ ~? err~~~~ ~ ~?

c. Do vou have anv knowledae of his/her havino suffered from anv illness or

4

Y. '* ~ \l@C!ifl«ll ~~ ","llOIl<'llii$1 ~~ lf1 ~ ~ ? '* ~ Y~IC!ifl$t ~ GlllOIl<'llii$t ~ <1R cmrr ~~ ~, 3NCIT ~~ ~~~GiWIT~~7 Did you discuss with the proposer / proposed the status of previous policies and are you satisfied that no policy has lapsed I been surrendered within the last 3 years?

~. '* ~ \il1'1ifl,f1lO1l Y@C!ifl$1 ~ mTCf err ~ ~'1'Jf\lI<or ~, ~ CIT

~~errW~~~? 5. Are you aware of any proposal (or revival of any policy) of the life proposed

having been declined dropped or accepted at terms other than those proposed?

\. '* ~ c:ftfmrq,1 ~ ~~, ~ err ~~ en ~~ ~ iltl ..j'jIil11"j$1 <lftl:rr ~ ~ ~ oro ~~~ ~ ?

6. Are you aware of anything In the occupation. financial or social position of the life proposed his/her personal habits or any other circumstances which might be likely to add to the risk ?

'-'. *~ mm ~~ ~~ orron mTCfifl!~ ~ "*r <r1 ~ ~p

7. Have you explained fully the terms and the conditions of the plan to the proposer?

c:;. ~ lffu;r ~ Y@C!ifl<6l ~ 8. For non-medical cases only.

'*' fcroq ~ (~n a. Identification marks

lil. ~ mtlftcl; ifflT ~ if.1fT. "lIT I ;;it;r fq;. m."lIT I b Actual Physical Measurement Height in cm ...J Weight in kg ~ _

11 lit ~~ f'q; ~ ~~ l1Ifll ~ ~ f41i1(OI{;~ ~"( ID;;IT W( I I hereby declare that the foregoing statements are true and correct to the best of my knowledge and belldt.

~ I Place _

nmr I Date: ~ i year ~ I Month mt / Date ~~ I Agent's Signature

~~;;f. (STO~m) Contact Tel. No. with STD Code

(¥4Thl'1<N 3{fucm: ~ dlf~M:I(1 ~) (To be completed by authorised person of the company)

11 1JI~11iIct>qi) fil"'If!:lIc ~~ am 11 ~ ~ ~1'1f.:l'1<N 3l'rn'rolT ~~ f'q; ~ ~Cl(OIe;€, ~;;rf.r ~ ~ ~ I I ilro satisfied with the identity of the proposer and on the baSIS of my independent enquiries, I hereby declare that the foregoing statements are true and correct to the best of my knowledge and belief.

~ I Place---------­

fllfcf I Date: _

<n+f '( ~ I Name & Designation - _

ffiTm I Signature