CO Application Form

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ANNEXURE-I

FORMAT OF APPLICATION FOR CHIEF ORGANISER (LIC DIRECT)

Affix your recent

Passport size colour

Photograph here

1. Name in full (In English: Capital letters, Surname first)

2. Male/Female: ___________ 2A. Mother tongue ______________

3. Mailing address (do not repeat name)

PIN CODE

4. Telephone No. with STD Code Office _________________

Res. _________________

Mob. __________________

E-mail id ___________________________

5. Date of Birth ____________ Age in completed years as on 1.4.2015 _______ yrs

6. Educational Qualification:

7. Details:

A) DSE Code No. :

C) Date of engagement:

D) DMKT Unit:

1
E) Business Performance since inception:

FINANCIALYEAR NO. OF POLICIES TOTAL FIRST YEAR


PREMIUM

I hereby declare that all statements made in this application are true and correct to the best
of my knowledge and belief. I understand that in the event of any information being found
false or incorrect or not satisfying the prescribed eligibility criteria for [CHIEF ORGANISER (LIC
DIRECT)]SCHEME, 2015 my candidature is liable to be cancelled/ rejected at any stage of
selection.

Place :

Date :

(Signature of the Applicant)

For Direct Mktg. Unit use:

1. Details given by the applicant verified.

2. Whether any disciplinary action/complaint is pending / initiated:

3. Recommendations.

Signature of Unit In-Charge (with seal)

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