Dff5fk'R5«] a}+s lnld6]8

lwtf]kq ;fj{hlgs lgisfzgsf] s]Gb|Ls[t ljB'lto ;]jf btf{ kmf/fd

(C-ASBA Registration Form) l;= g+=

ldltM
>L df5fk'R5«] a}+s lnld68
============ zfvf
dxfzo,
d}n]÷xfdLn] ca pk/fGt x'g] lwtf]kqsf] ;fj{hlgs lgisfzgsf qmddf lwtf]kq vl/b-;fj{hlgs lgisfzg_ ;DalGw lgb]{lzsf,@)&#-bf];|f] ;+zf]wg, @)&$
;lxt_ cGtu{t vl/b ug{sf nfuL to; a}+sdf /x]sf] d]/f]÷xfd|f] vftf gDa/========================df vf]lnPsf] lxtu|fxL vftf gDa/=============================df
hDdf u/fpg] x'Fbf lwtf]kq vl/b k|of]hgsf] nfuL lgDg cg';d/sf] ljj/0f k|of]u ug{sf nfuL To; a}+sdf cfjZos Joj:yf ul/lbg' x'g d]/f]÷xfd|f] a}+s vftf
tyf lxtu|fxL vftf ;DalGw ljj/0f ;lxt of] lgj]bg k]z u/]sf] 5'÷5f}+.
a}+s vftfsf] ljj/0fM
vftf g+M(Account No.)
lsl;d(Type)

lxtu|fxL vftfsf] ljj/0f:

lgIf]k ;b:o g+(DPID)
lxtu|fxL g+(Client ID)

cfj]bssf] ljj/0f

cfj]bssf] gfd÷y/

Name of Applicant(BLOCK
LETTER)
gful/stf g+ hf/L lhNnf hf/L ldlt
Issued
Citizenship No. District Issued Date
:yfoL n]vf g+ sDklg b{tf g+-;+:yfsf] xsdf_

Pan No. Company Registration No(In case of Company)

:yfoL 7]ufgf(Permanent Address)
k|b]z lhNnf uf=kf=÷g=kf=÷p=d=g=kf÷d=g=kf
State District VM/Municipality /Sub-Metropolitan/Metropolitan
6f]n j8f g+ Ans g+
Tole Ward No. Block No.
6]lnkmf]g g+ df]afOn g+ Od]n 7]ufgf
Telephone No Mobile No. E-mail Address
xfnsf] 7]ufgf(Current address)
k|b]z lhNnf uf=kf=÷g=kf=÷p=d=g=kf÷d=g=kf
State District VM/Municipality /Sub-Metropolitan/Metropolitan
6f]n j8f g+ Ans g+
Tole Ward No. Block No.
6]lnkmf]g g+ df]afOn g+ Od]n 7]ufgf
Telephone No Mobile No. E-mail Address
a'jfsf] gfd
Father's Name
cfdfsf] gfd
Mother's Name
 xh'/a'jfsf] gfd
Grandfather's
name
klt÷klTgsf]gfd
Spouse's Name
;+/Ifssf] gfd-
gfafnssf] xsdf_
Guardian's
name(In case of
Minor)
;+:yfsf] tkm{af6 eP
clVtof/ k|fKt JolQmsf]
gfd kbM
cGo M
k'gZrM

dfly pNn]lvt ljj/0f k|of]u u/L, to; a}+sn] k+bfg u/]sf] /lhi6«]zg g+=(CRN Number) pNn]v u/L lwtf]kq vl/b cfj]bg lbbfF l;l8P;\l;n] k|bfg u/]sf]
OG6/g]6df cfwfl/t ;]jf æd]/f] z]o/Æ dfkm{t\ jf To; a}+ssf] zfcfx?df pknAw ef}lts cfj]bg kmf/fd e/]/ a'emfP afkt d]/f]÷xfd|f] vftfdf df}Gbft /x]sf]
/sd /f]Ssf /fVg tyf afF8kmfF8 kZrft\ k|fKt x'g] lwtf]kq lgisfzg tyd laqmL k|aGwsf] vftf dfkm{t\ lgisfzgstf{ sDklgsf] vftfdf
:yfgfGt/0f(Transfer) u/fpg ;fy}, To; a}+sn] ;fj{hlgs ?kdf pNn]v u/]sf] lwtf]kq vl/b lgj]bg z'Ns ;d]t ;f]xL vftfaf6 s§f u/L c;'n pk/ ug{
d]/f] xfd|f] dGh'/L /x]sf] 5.

=============================== ==================================
cfj]bssf] b:tvt 5fk -;+:yfsf] xsdf_
Applicant’s signature Stamp(For Institution)
lwtf]kq ;fj{hlgs lgisfzgsf] s]Gb|Ls[t ljB'lto gDa/-cfj]bgstf{sf] k|lt_
C-ASBA Registration Number (Applicant’s Copy)

cfj]bgstf{sf] gfd (Applicant’s name): …………………………………………………………………

vftf g+=(Account No.):

CRN No. ………………………………