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    Nomination Form: Balewadi, Baner Road, NIA P.O., Pune 411 045 (India)

    Uploaded by

    Amer Yehia
    This document is a nomination form for an insurance training programme. It requests information such as the nominee's name, job details, passport information, medical history, and tentative travel plans. Payment details are also requested, including the bank transfer details and programme fee amount. The form is to be filled out by the nominee and signed, and also signed by the nominating authority.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Nomination Form: Balewadi, Baner Road, NIA P.O., Pune 411 045 (India)

    Uploaded by

    Amer Yehia
    31 views1 page
    This document is a nomination form for an insurance training programme. It requests information such as the nominee's name, job details, passport information, medical history, and tentative travel plans. Payment details are also requested, including the bank transfer details and programme fee amount. The form is to be filled out by the nominee and signed, and also signed by the nominating authority.

    Original Description:

    Nomination Form

    Original Title

    Nomination Form

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    This document is a nomination form for an insurance training programme. It requests information such as the nominee's name, job details, passport information, medical history, and tentative travel plans. Payment details are also requested, including the bank transfer details and programme fee amount. The form is to be filled out by the nominee and signed, and also signed by the nominating authority.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    31 views1 page

    Nomination Form: Balewadi, Baner Road, NIA P.O., Pune 411 045 (India)

    Uploaded by

    Amer Yehia
    This document is a nomination form for an insurance training programme. It requests information such as the nominee's name, job details, passport information, medical history, and tentative travel plans. Payment details are also requested, including the bank transfer details and programme fee amount. The form is to be filled out by the nominee and signed, and also signed by the nominating authority.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Balewadi, Baner Road, NIA P.O., Email: programoffice@niapune.org.

    in;
    Pune 411 045 (India) contactus@niapune.org.in
    Tel.: +91-20-27204000/27204444

    NOMINATION FORM

    Programme Name: Click here to enter text.


    Programme Dates: From Click here to enter a date. To Click here to enter a date.
    Name of the Company: Click here to enter text.
    Click here to enter text.
    Company Mailing Address:
    Click here to enter text.
    Company Tel/Fax Nos. with ISD/Area Click here to enter text. Fax Nos.: Click here to enter text.
    Code:
    Company Email ID: Click here to enter text.
    Full Name: Mr./Ms. First Name Middle Name Last Name
    Position held: Click here to enter text.
    Date of Birth: Click here to enter a date. Nationality: Click here to enter text.
    Passport No.: Click here to enter Date & Place of Issue: Click here to enter Valid up to Click here to
    Tel. /Mob. No. with ISD text.
    and Area Click here to enter text. enter a date.
    E-mail Id: Click here to enter text.
    Code: text.
    Emergency Contact Person Name & Tel No.
    Click here to enter text.
    with ISD and Area Code:
    Qualifications (a) Academic: Click here to enter text. (b) Professional: Click here to enter text.
    No. of years’ experience in Insurance, present role and functions in brief:
    Click here to enter text.
    Click here to enter text.
    Details of Technical Programmes attended so far: Click here to enter text.
    Click here to enter text.
    Click here to enter text.
    Any Adverse Medical History:
    a) Heart Click here to enter text.
    b) Diabetes Click here to enter text.
    c) Kidney Click here to enter text.
    d) Asthma Click here to enter text.
    e) Any other Click here to enter text.
    PROGRAMME FEE PAYMENT DETAILS
    Bank transfer details: Click here to enter text. Fee Amount: Click here to enter
    Bank Name: Click here to enter text. text.
    TENTATIVE TRAVEL PLAN (only for overseas participants)
    Date Flight No. From Departure Time To Arrival Time
    Click here Click here to enter text. Click here Click here to enter Click here Click here to enter
    to enter
    Click herea Click here to enter text. to enter
    Click here text.
    Click here to enter to enter
    Click here text.
    Click here to enter
    date.
    to enter text. text.
    Click herea Click here to enter text. to enter
    Click here text.
    Click here to enter to enter
    Click here text.
    Click here to enter
    date.
    to enter text. text.
    Click herea Click here to enter text. to enter
    Click here text.
    Click here to enter to enter
    Click here text.
    Click here to enter
    date.
    to enter a text.
    to enter text. text.
    to enter text.
    date. text. text.

    Signature of the Nominee Signature & Seal of the Nominating Authority

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