5.

IN S TR U C TIO N S FO R FILLIN G TH E FO R M
PLE AS E FO LLO W TH E SIM P LE STEPS W H ILE FILLIN G THE FO R M S
1. 2. Use the B LACK B AL L PEN to fill the details and to sign the form . Do not put any stray m arks on Black Squares and Barcode.

3. Fill com plete circles for the selected options else leave it blank if not applicable as shown in the exam ple:

4. W rite clearly within the boxes, as indicated in the following exam ple:

5. 6. 7. 8.

Do not over write. Please write the date in DD-M M -YYYY form at. Do not bend/fold the form . Please refer the table below for State Codes.
S T AT E /U T N AM E ANDAMAN AND NICOBA R ANDHRA PRADES H ARUNACHAL PRADES H ASSAM BIHA R CHANDIG ARH CHHATISGARH DADRA AND NAGA R HAVE LI DAMAN & DIU DELHI GOA GUJARAT HARYANA HIMACHAL PRADES H JA MMU & KAS HMIR JHARKHAND KA RNATAKA KE RALA S T ATE /U T C O D E LK MP MH MN MG MZ NG OR PN PB RJ SK TN TR UP UT WB S T AT E /U T N AM E LAKS HADEEP MADHYA PRADESH MAHARAS HTRA MANIPUR MEGHALAYA MIZORAM NAGALAND ORISSA PONDICHERRY PUNJA B RAJAS THAN SIKKIM TAMIL NADU TRIPURA UTTAR PRADESH UTTARAKHAND/UTTRANCHAL W ES T BE NGAL

S T ATE /U T C O D E AN AP AR AS BH CH CG DN DD ND GA GJ HR HP JK JH KR KL