SPONSORSHIP FORM

For DTC Purpose: URN NO. IR NO SL.NO Sponsoring Company Name In Charge/Authorised Person Name Licence Type Insurance Category Is Specified Person? : : : : : Branch Name : D.O Code Number D.O Mobile Number MR No. & Dt. MR No/Cheque No. S.L.NO. : : : :

LIFE INSURANCE CORPORATION OF INDIA ( ( ( ) INDIVIDUAL ) LIFE ) YES ( ( ( ) CORPORATE ) GENERAL ) NO If YES, Licence No:

Applilcant Details
Application Date (DD/MM/YYYY) :

Personal Information:
Applicant Name Father/Husband Name Category Area PAN ( ) Driving Licence No.( ) Passport No. ( ) Voter Identity Card* ( ) Photo ID Card of Govt. ( ) Basic Qualification Details Board Name: Roll Number: Year of Passing: ( ( : : : : : : Class X/ Class XII ) General ) Urban ( ( ) SC ) Rural ( ) ST ( ) OBC Applicant Photo

Applicant Signature
Any of below: ( ) Class X ( ) Class XII ( ) Graduate ( ) Post Graduate ( ( ( ( ( ( ) Associate/ Fellow of Insurance Institute of India ) Associate/Fellow of Institute of Cost and Works Accounts of India ) Associate/Fellow of Institute of Company Secretaries of India ) Associte/ Fellow of Acturial Society of India ) Master of Business Administration ) Others:

Educational Qualification

Date of Birth (DD/MM/YYYY): Sex: Primary Profession: Nationality: Current Address: House Number: Street/ Road: Town/ City: State: District: PIN Code: Res. Number Mobile No: email id: Other Information: Training at A.T.C. / D.T.C Examination Mode Examination Body Examination Center Examination Language Permanent Address: House Number Street/ Road Town/ City State District PIN Code Res. Number: Mobile No: email id: DIVISIONAL TRAINING CENTER ) ONLINE ( ) Offline INSURANCE INSTITUTE OF INDIA NSEiT, VISAKHAPATNAM ( ) ENGLISH ( ) TELUGU

: ( : : :

(Signature of Applicant) Authorised Signature with Stamp CM/ SBM/ BM/ ABM/ PRINCIPAL (Signature of DO / SBA) Date: CDO/0057767/69P