Insrrucrons. All details to be tllled in Block Lett.

rs (lo be volid lor 3 months lrom date ol issue)

To be printed on ploin A4 poper size; Not required to print on lelter heod; 03 o t. >o >>
Resident Non-Resident lndlan (NRl) New €nrolment Update Request

Aadhaar Numberi
(for update ohly) 698398359702
FullNamel PAGOT MU LAYYA

Clot TATAYYA
House No./ Bldg./ Apt; 1-1
Street/ Road/ Lane: i(ONDI VEE DHI
Landmarkl

Area/ l-ocality/ Sector: KATVI AKAYA .

Village/ Town/ City: KAMBAKAYA I

Post Office: KAMBAKAY A

District: SRIKAKULAMi
State: ANDHRA PIRADE.SH.

PIN Codei 532421

r)
Dete of Birth: 01 01 11965
a HosPl
Certifier's Details be filled the certifier Only)
Name of the Certifier
D{ S lK ,i,r's i
^cf
Pd-
Designation: civt. t
Offlce Address:

Contact Number:

I hereby certify above mentioned debilr ofthe resident Checklistfor certifier

and I m a.... (Tlck appropriate box below) fit/tg overwrttins Efl*" our" ,,0,,"0 fttiiaenils signatu." 96?** d",",,.
Gazetted Officer - Group A ffn"rio"nr, plio islss signed and crossstam ped (popei to photo or photo to popet)
village Panchayat Head o. Mukhiya
cazeued officer - Group B ,
MP/ MW MLC/ Munaipal councilor
tenSloar
Head of Recogriized Educational lnstitutiqn

Superintendent/ Wlrden/ Matron/ Head of lnstitution shna Rao

of Recogriil6d she]tet homb, Orphanages N I3 MS GS)
ist
EPFOOfffceti ..' ,
aram
aram iS
l6an+
rr^ 1, ^I a.ho.l,,l6 rr
^arlio ?l!.lh!.r lrn'