SPONSORSHIP FORM

For DTC Purpose: Branch Name : S.L.NO.

URN NO. D.O Code Number :
D.O Mobile Number :
IR NO MR No. & Dt. (Rs.150/-) :
SL.NO MR/Cheque No.(Rs. 350/-) :

Sponsoring Company Name : LIFE INSURANCE CORPORATION OF INDIA

In Charge/Authorised Person Name :
Licence Type : ( ) INDIVIDUAL ( ) CORPORATE
Insurance Category : ( ) LIFE ( ) GENERAL
Is Specified Person? : ( ) YES ( ) NO If YES, Licence No:

Applilcant Details
Application Date (DD/MM/YYYY) :
Personal Information:
Applicant Name
Father/Husband Name
Category ( ) General ( ) SC ( ) ST ( ) OBC
Area ( ) Urban ( ) Rural
PAN ( ) :
Driving Licence No.( ) :
Passport No. ( ) :
Voter Identity Card* ( ) :
Photo ID Card of Govt. ( ) :
Basic Qualification Details : Class X/ Class XII
Board Name:
Roll Number:
Year of Passing:
Educational Qualification Any of below:
( ) Class X ( ) Associate/ Fellow of Insurance Institute of India
( ) Class XII ( ) Associate/Fellow of Institute of Cost and Works Accounts
( ) Graduate ( ) Associate/Fellow of Institute of Company Secretaries of In
( ) Post Graduate ( ) Associte/ Fellow of Acturial Society of India
( ) Master of Business Administration
( ) Others:

Date of Birth (DD/MM/YYYY):

Sex:
Primary Profession:
Nationality: INDIAN
Current Address: Permanent Address:
House Number: House Number
Street/ Road: Street/ Road
Town/ City: Town/ City
State: State
District: District
PIN Code: PIN Code

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 Res. Number Res. Number:
Mobile No: Mobile No:
email id: email id:

Other Information:
Training at A.T.C. / D.T.C :
Examination Mode ( ) ONLINE ( ) Offline
Examination Body : INSURANCE INSTITUTE OF INDIA
Examination Center :
Examination Language : ( )ENGLISH ( )HINDI ( )

(Signature of Applicant)

Authorised S
CM/ SBM/ BM
(Signature of SBA)

Date:

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SORSHIP FORM

If YES, Licence No:

Applicant Photo

Applicant Signature

Associate/Fellow of Institute of Cost and Works Accounts of India

Associate/Fellow of Institute of Company Secretaries of India

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 Authorised Signature with Stamp
CM/ SBM/ BM/ ABM/ PRINCIPAL

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