Two Passport size photograph duly attested by Accredited
Training Institute
APPLICATION FORM
Insurance Brokers Examination
(Please strike whichever is not applicable)
DIRECT LIFE \ DIRECT GENERAL \ DIRECT LIFE & GENERAL \
REINSURANCE \ COMPOSITE
Date of the Examination : 27 th
July, 2014
Centre for Examination : Pune/ Chennai/ Mumbai/ Kolkata/ Delhi
1) Name of the candidate: _________________________________________
2) Address : _________________________________________
_________________________________________
Mobile:   _________________________________________
Tel.:     ___________________________________________
Email:   __________________________________________
3) Name and Address of the Training Institute:
________________________________________________________________
_______________________ __________________________________________
Mobile/Tel.:_________________________Email:__________________________
4) Educational Qualifications
*
__________________________________________
5) Professional Qualifications
*
__________________________________________
( * Candidate must enclose an attested Xerox copy Degree Certificate)
6) Number of Hours Training undergone: 50 Hrs./ 25 Hrs. (strike out not applicable)
7) Certificate of Training Institute attached: Yes / No
8) Have you appeared earlier for this exam. : Yes/No
9) If yes, old registration number__________________________________________
10) Optional subjects: __________________________________________
11) Examination fees : Rs.3,000/- by DD No. ___________ dated _______ drawn on __________________________________ in favour of `National Insurance Academy’ payable at
Pune attached/sent separately by the institute
______________________ _________________________________
Signature of the Candidate Signature of the Authorized Officer of the Accredited Training Institute with stamp