AGREEMENT FORM

Planning Commission, Government of

Gujarat
To be filled by the Enrolment Agency: - LIFE LINE INFOSY
please follow the instructions overleaf while filling up the form. Use
capital letters only.

1- Full Name:2- Gender: - Male ( ), Female ( )

3- Age:Yrs OR Date of Birth:4- Address:5- House No/Bldg./Apt.:6- Landmark:7- Village/Town/City
8- District:9- E-Mail:10Mobile No.:11Pin Code:12Your Bank Account No.:13Bank Name:Branch:14Transactions ID No.:-

Street/Road:-

Date:-

15-

Pre-Enrolment ID:- (Office Used)

I confirm that information provided by me to the Vision Software & Date Services and the
information contained herein is my own and is true, correct and accurate.

Applicants
signature
Date:/ /2014
Place:- ___________________

BF; ;]RGFv VF VZHL 5+S ;FY[ VF.P0L 5|]OGL GS, VG[ V[U|LD[g8 OL GL A[\S
Z;LN GL GS, .vD[., YL Z_q_!qZ_!5 ;]WLDF\ DMS,JFG]\ ZC[X[P