Register Of Notaries Form IIA

(FORM II) (Rule 4(2)) 1.Name_______________________ __________ 2.Father's/Husband’s name ____ __________________________ 3.Date of birth _______ _________________________ 4.Whether SC/ST/OBC/General___________________________ 5.Address(Residence)_____________________________________________________ PIN___________________ Telephone__________________Fax_____________E-mail______________________ Address(office)_________________________________________________________ __________________________ PIN ____________________________________ Telephone ________________ Fax _________________ E-mail _________________ 6. Educational qualifications______________________________________________ 7. Date of joining government service _______________________________________ 8. Date of retirement_____________________________________________________ 9. Post held at the time of retirement______________________________________ 10. Area where the memorialist intends to practice as Notary _________________________________________________________ Signature of the applicant Dated_____________ day of ____________ 20_____________ PHOTOGRAPH Annexure Statement of Column 10(3) Due to increase in school, college, industries, litigation works and increasing population etc.

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