7/8/2015 RecruitmentofAssistantinUnitedIndiaInsuranceCompanyLimited[UIICL]ApplicationFormPrint

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RegistrationNumber : 500038242

FullName : VENNELAKANTIPAVANKUMAR

State/UTforExam: : AndhraPradesh

ExaminationCentres : Gondlavelleru

Category : UR

AreyouaPersonwithDisability : NO

TypeofDisability :

PercentageofDisability :

Areyousufferingfromcerebralpalsyandyourwritingspeedisaffected?

:

IfYes,Doyouneedcompensatorytimeatthetimeofexamination?

:

Whetheryourdominant(Writing)handaffected? :

IfYes,Doyouneedcompensatorytimeatthetimeofexamination?

:

Doyouintendtousetheservicesofascribe(onlyforB/LVandthecandidateswhosewritingspeedispermanentlyaffected)?

:

WhetherPersonsdomiciledinJammu&Kashmirduringtheperiodfrom01.01.1980to31.12.1989

: NO

Religiontowhichyoubelong : Hindu

WhetheryoubelongtoReligiousMinorityCommunity? : NO

DoyouhavetheKnowledgeofRegionalLanguageoftheState : YES

AreyouanExServiceman : NO

AreyouaDisabledExServiceman(DISXS)? :

IfYes,DateofDischarge: :

ActualservicerenderedindefenceserviceswhichmaybecountedforqualifyingasanExserviceman(InMonths)

:

AreyoudependantofServicemankilledinaction(DXS)?: : NO

AreyouDisplacedpersonsfromEastPakistanwhohavemigratedtoIndiaonorafter01.01.1964

: NO

AreyouExistingEmployeesofUnitedIndiaInsuranceCo.Ltd? : NO

IfYes,EmployeeNo. :

Designation :

PlaceofWork :

AreyouResidentofAssamStateduringtheperiodfrom01.01.1980to15.08.1985?

: NO

AadharCardNo. : 900544389787

UnitedIndiaInsuranceCompanyLimited[UIICL]RecruitmentofAssistant

7/8/2015 RecruitmentofAssistantinUnitedIndiaInsuranceCompanyLimited[UIICL]ApplicationFormPrint

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Nationality: : Indian

ApplicationFeeDetails:

PaymentIn : ONLINE

Amount : 450.00

PaymentStatus : PAID

ReferenceID : DSBI3892040465

TransactionDate : 08072015

PersonalDetails

DateofBirth : 02011990

Agecompletedason30.06.2015 : 25

Gender : MALE

MaritalStatus : Unmarried

Father'sName : Vrajasekhar

Mother'sName : vbalatripurasundari

Spouse'sNameinFull :

AddressforCorrespondence : DNO27271

: KOJJILLIPET

: MACHILIPATNAM

District : KRISHNA

State : ANDHRAPRADESH

Pincode : 521001

PermanentAddress : DNO27271

: KOJJILLIPET

: MACHILIPATNAM

District : KRISHNA

State : ANDHRAPRADESH

Pincode : 521001

ContactDetails

PhoneNo :

MobileNo : +919581971732

EmailID : ramanujan.pavan@gmail.com

QualificationDetails(ason30.06.2015)

ExamPassed Subject/Stream DateofPassing

%ofMarks Class/Grade

HSC/Equivalent MPC 31032007 87.80 FirstClass

Graduation/Equivalent Science 31032013 80.11 FirstClass

7/8/2015 RecruitmentofAssistantinUnitedIndiaInsuranceCompanyLimited[UIICL]ApplicationFormPrint

http://ibps.sifyitest.com/uiiclasjul15/registration_print.php?q=NzdjYTNhMjJjOGI1ZjM5NjE3NmExMWNiYzk1YzhkNGZ8NTAwMDM4MjQy 3/3

LanguagesKnown Read Write Speak

English YES YES YES

Hindi YES YES NO

TELUGU YES YES YES

LanguageDetails:

DECLARATION

IherebydeclarethatallthestatementsmadeinthisapplicationareTrue,CompleteandCorrecttothebestofmyknowledgeandbelief.IunderstandthatintheeventofanyinformationbeingfounduntrueorincorrectatanystageorIamnotsatisfyinganyoftheeligibilitycriteriastipulated,andalsoincaseofcreatinginfluence/unduepressureregardingrecruitmentshalltantamounttocancellationofmycandidature.

Date:08072015 SignatureofApplicant