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IN S TR U C TIO N S FO R FILLIN G TH E FO R M PLE AS E FO LLO W TH E SIM P LE STEPS W H ILE FILLIN G THE FO R M S 1. D o not over write. 7. 4. D o not put any stray m arks on Black Squares and Barcode. S T AT E /U T N AM E ANDAMAN AND NICOBA R ANDHRA PRADES H ARUNACHAL PRADES H ASSAM BIHA R CHANDIG ARH CHHATISGARH DADRA AND NAGA R HAVE LI DAMAN & DIU DELHI GOA GUJARAT HARYANA HIMACHAL PRADES H JA MMU & KAS HMIR JHARKHAND KA RNATAKA KE RALA Page 6 of 6 S T ATE /U T C O D E LK MP MH MN MG MZ NG OR PN PB RJ SK TN TR UP UT WB S T AT E /U T N AM E LAKS HADEEP MADHYA PRADESH MAHARAS HTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ORISSA PONDICHERRY PUNJA B RAJAS THAN SIKKIM TAMIL NADU TRIPURA UTTAR PRADESH UTTARAKHAND/UTTRANCHAL W ES T BE NGAL S T ATE /U T C O D E AN AP AR AS BH CH CG DN DD ND GA GJ HR HP JK JH KR KL . Please write the date in DD -M M -YYYY form at. U se the B LACK B AL L PEN to fill the details and to sign the form . W rite clearly within the boxes. Please refer the table below for State Codes. D o not bend/fold the form . as indicated in the following exam ple: 5. 2. 6. 8. Fill com plete circles for the selected options else leave it blank if not applicable as shown in the exam ple: 3.

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