GOVERNMENT OF PONDICHERRY DISTRICT INDUSTRIES CENTRE ***** APPLICATION FORM FOR GROUP INSURANCE SCHEME FOR HANDICRAFTS ARTISANS 1. Name of the Artisan : 2. Father/Husband's name : 3. Name of the Crafts : 4. Permanent address : 5. Unit address : 6. Whether belongs to SC/ST : YES/NO 7. Age & date of birth : 8. Permanent Regn. No: &Date : 9. Whether he/she has been trained by DIC : YES/NO ( if so, in which year/ Name of the Master Trainer) 10. Nominee name : 11. Nominee father's name : 12. Nominee address : ..2 - 2 - 13. Nominee date of birth : 14. Nominee present age : 15. Nominee relationship : 16. Whether the Artisan or nominee has already been assisted under the scheme 'Janashree Bima yojana Insurance' : YES/NO scheme of LIC? Place : Signature of the applicant with seal Date : DECLARATION I hereby declare that the information furnished above are true to the best of my knowledge and in case, any false information found in the future, I abide to hold full responsibility. Signature of the applicant with seal. N.B: The application should be accompanied with proof for the items mentioned in the Sl .No: 6,7,8,9, & 13.
