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ANNEXURE A (to be completed and e-mailed to co_cliapp@licindia.com) APPLICATION FOR AUTHORISATION TO BE USED BY CLIAs Name: Dharmpal Sharma Address ( With Pin Code ):S/o. Om Prakash Sharma (Po)P-Pai 136 027 Mobile No:9255152855E-mail ID:dharmpalsharma734@yahoo.comBranch:Kaithal (339)Division :Zonal Manager Agency Code Number :00917339 MClub membership (Corporate/CM/ZM/DM):ZMCLIA Code No.:M00917339M(10) No. of supervised agents:1(11)Do you have a computer? Yes/Desktop(12)Do you have a laser printer?:Yes/ Laser Printer (13)Do you have Internet connectivity?:Yes/Broadband (BSNL) (In the absence of computer, printer and internet, the authorization will notbe given) dharmpalsharma734@yahoo.commailto:

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ANNEXURE_A
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