LUroorO/ self Declar.

tiotr

A@'4istn adL!6, C..u6{ruri dL-is dLLri, Bt-LJiudu6

q*t t ..*iqa, r .rq '- 0. c. q! i arc.i- '4i!ri 36DJ rlce"d0
ar-rn- Cuui ,q .rttanf *a! ,i, .t!-t' dPidDLL ,l.dd!'n
*i'a .-.Ii!dit !&d'@!' n.5d
9,a !,6i/' .5ra- L-o
rt .ra.i./ {o-ix'i Li''!'o
,-q6, t.i .||.nit
-"r.*ir,- * s--JL, Old@clb -:,ir.' li& !-rL..4i 'i!6 r??
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6ro rnc-l aU ddig i4r'. Glrrutr- Flaj.l Cqin-*ntuo'i
o*rot rflcori ndlg ErldAdro .{db.iia-CD-'
I am Tit. t.j.sq.ri d:!qhr.r of Thlru v€er*arry residi'O ai O@' No' 75' street of
Nagar villaq. / tdh of Gornd.npilavam. Taluk of coihbatore North, coimbaroE
'*va
Dkli'r' Tamil
Nadu state. Tte dclails futnnh.d bY me ar. vue io the b.tt of mY kndledg' and
believe rnd
fact ihlt if lhe infornalion
norhing has b*n .o...al.d h€Iein. I delare thrt I am well awaE of th'
.nd docum.6 given by m are prokd 1o b. in.or'd / not r/u' in tulur€' I shtll b' liable for
obtecurio n u nder 3*r ion 177 & l99olthe lndlah PcnalCode'

ltted,teit
of rh. applratrt / DgF Ii- d6udu'l
Sradrur