cg';"rL $

bkmf % sf] pkbkmf -!_ ;+u ;DalGwt C-ASBA Registration No.

(CRN No.)
lwtf]kqsf] ;fj{hlgs lgisfzgsf] s]Gb|Ls[t ljB'tLo ;]jf btf{ kmf/d
C-ASBA Registration Form
ldlt/Date :...............................

d}n÷] xfdLn] ca pk/fGt x'g] lwtf]kqsf] ;fj{hlgs lgisfzgsf qmddf lwtf]kq vl/b -;fj{hlgs lgisfzg_ ;DaGwL lgb]l{ zsf, @)&# -bf]>f] ;+zf]wg, @)&$ ;lxt_ cGtu{t vl/b ug{sf
nflu To; a}s + df /x]sf] d]/f]÷xfd|f] vftfdf df}Hbft /x]sf] /sd k|of]u u/L vl/b ug{ tyf afF8kmfF8 ePkl5 k|fKt x'g] lwtf]kq======================================================================================
df vf]lnPsf] lxtu|fxL vftfdf hDdf u/fpg] x'bF f lwtf]kq vl/b k|of]hgsf] nflu lgDg cg';f/sf] ljj/0f k|of]u ug{sf nflu To; a}s + df cfjZos Joj:yf ul/lbg' x'g d]/f]÷xfd|f] a}s + vftf
tyf lxtu|fxL vftf ;DaGwL ljj/0f ;lxt of] lgj]bg k]z u/]sf] 5'÷5f}+ .
a}s
+ vftfsf] ljj/0f
vftf gDa/ M
A/C Number :
lsl;d M vftf /x]sf] zfvf M
Type :

lxtu|fxL vftfsf] ljj/0f M

lgIf]k ;b:o gDa/ M
(DPID)
lxtu|fxL gDa/ M
(Client ID)

cfj]bssf] ljj/0f M
cfj]bssf] gfd÷y/
Name of Applicant

gful/stf gDa/ M hf/L lhNnf M hf/L ldlt M

Citizenship No.: Issue District Issue Date

:yfoL n]vf gDa/ M sDkgL btf{ gDa/ M

-;+:yfsf] xsdf_
Company Registration No.:
PAN No. :
(In case of Institution)
:yfoL 7]ufgf (Permanent Address):
c~rn M lhNnf M uf=kf=÷g=kf=÷d=g=kf=
Zone : District : V.M/Municipality/Metropolitan :
6f]n M j8f g+= M Ans g+= M
Tole : Mobile No.: Block No.:
6]lnkmf]g g+= M df]jfOn g+= M O{dn] M
Telephone No.: Mobile No.: E-mail ID :
xfnsf] 7]ufgf (Current Address):
c~rn M lhNnf M uf=kf=÷g=kf=÷d=g=kf=
Zone : District : V.M/Municipality/Metropolitan :
6f]n M j8f g+= M Ans g+= M
Tole : Mobile No.: Block No.:
6]lnkmf]g g+= M df]jfOn g+= M O{dn] M
Telephone No.: Mobile No.: E-mail ID :

afa'sf] gfd M
Father's Name
(BLOCK Letter)
afh]sf] gfd M
Grand Father's Name
(BLOCK Letter)
klt÷kTgLsf] gfd M
Spouse's Name :
(BLOCK Letter)
;+/Ifssf] gfd M
-gfafnssf] xsdf_
Guardian's Name :
(In case of Minor)

;+:yfsf] tkm{af6 eP clVtof/ k|fKt JolQmsf] gfd M kb M

cGo M

=================================================================================== ========================================
cfj]bssf] b:tvt÷cleefjssf] b:tvt -gfafnssf] xsdf_ 5fk -;+:yfsf] xsdf_
Applicant's Sign./Guardian Sign (If Minor) Stamp (For Institution)
 -cg';"rL %_
-bkmf * sf] pkbkmf -!_ ;+u ;DalGwt_

>L Hof]lt ljsf; a}s + ln=

;fj{hlgs lgisfzg lwtf]kq vl/b tyf /sd /f]Ssf cfj]bg kmf/d
=========================zfvf . ldltM

ldlt ===============================b]lv ldlt=================================;Dd lgisfzg x'g] b]xfo cg';f/sf] lwtf]kq vl/b ug]{ OR5f ePsfn] ;f] sf] nflu of] lgj]bg u/]sf] 5' .
lgisfzgstf{ sDkgLsf] gfd M
lwtf]kq hf/L ug]{ ;+:yfsf] gfd M lwtf]kqsf] lsl;d M
lxtu|fxL -l8Dof6_ vftf gDa/ M
cfj]bgsf] k"/f gfd, y/ M
Name of Applicant (IN BLOCK LETTER)

/sd /f]Ssf /fVg] a}s

+ vtf gDa/ M

zfvfsf] gfd, 7]ufgf M

/lhi6]z
« g gDa/ M
(C-ASBA Registration Number)

lwtf]kqsf] ;+:yf M k|lt lwtf]kq vl/b /sd M

c+sdf M c+sdf M
cIf/df M cIf/df M
hDdf /sd M
c+sdf M
cIf/df M
pko'Q{ mfg';f/ lwtf]kq vl/bsf nflu cfjZos x'g] /sd d]/f] a}s
+ vftfdf df}Hbft /x]sf]n] pQm /sd /f]Ssf /flv lbg' x'g cg'/f]w ub{5' . lwtf]kq afF8kmfF8 ePkl5 d]/f] gfddf lwtf]kq
afF8kmfF8 x'g] ePdf pQm /sd d]/f] vftfaf6 lgisfzg tyf laqmL k|jGwssf] vftf dfkm{t\ lgisfzgstf{ sDkgLsf] vftfdf /sdfGt/sf nflu d]/f] dGh'/L /x]sf] 5 . ;fy}, a}s + n] ;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 .

=================================================================================== ========================================
5fk -;+:yfsf] xsdf_
cfj]bssf] b:tvt÷cleefjssf] b:tvt -gfafnssf] xsdf_ Stamp (For Institution)
Applicant's Sign./Guardian Sign (If Minor)

lwtfkq vl/bsf nflu /sd /f]Ssf ;DaGwL cw{s§L

-cfj]bgstf{ k|lt_
lwtf]kq vl/b ug]{ k|of]hgsf] nflu tkfO{+n] k]z ug'{ ePsf] lwtf]kq vl/b tyf /sd /f]Ssf cfj]bs kmf/fd cg';f/ b]xfo cg';f/ tkfO{+sf] a}+s vftfdf /sd /f]Ssf
ul/g]5 . lwtf]kq afF8kmfF8 ePkl5 tkfO{s
+ f] gfddf afF8kmf8 x'g] lwtf]kq a/fa/sf] /sd tkfO{s
+ f] /f]Ssf /x]sf] /sdaf6 lgisfzg tyf laqmL k|jGwssf] vftf dfkm{t\ lgisfzgstf{
sDkgLsf] vftfdf /sdfGt/ ul/g]5 .
lgisfzgstf{ sDkgLsf] gfd M
lwtf]kq hf/L ug]{ ;+:yfsf] gfd M lwtf]kqsf] lsl;d M
lxtu|fxL -l8Dof6_ vftf gDa/ M
cfj]bssf] k"/f gfd, y/ M
Name of Applicant
(IN BLOCK LETTER)
lwtf]kqsf] ;+Vof M k|lt lwtf]kq vl/b /sd M
c+sdf M c+sdf M
cIf/df M cIf/df M
hDdf /sd M
c+sdf M
cIf/df M
k|dfl0ft ug]{ clwsf/Lsf] gfd M
kb M
b:tvt M
ldlt M
a}s
+ sf] gfd, 7]ufgf / 5fk M Hof]lt ljsf; a}s
+ lnld6]8==================================zfvf .