(Circular CO/CLIA /ZO/88/20/1)

(To be Complete and e-mailed to co_cliapp@licindia.com)

APPLICATION FOR AUTHORISATION TO BE USED BY CLIAs

(1) Name:- PAVAN KUMAR GUPTA

(2) Mailing Address- (With Pin Code):- SHIV COLONY, GOVERDHAN ROAD, CHHATA, MATHURA
(UTTAR PRADESH)- 281401
(3) Mobile No:- +91-9027130294
(4) Email ID:- pkg8531@gmail.com
(5) Branch:- KOSIKALAN
(6) Division:- ALIGARH
(7) Agency Code No:- 0407726B
(8) Club Membership (Corporate/CM/ZM/DM):- ZM CLUB
(9) CLIA Code NO:- M003226B
(10) A. No. Of Supervisor Agents
B. Agency code of at any One Supervised agent
(11)Do you have a computer? Desktop/Laptop/both laptop
(12)Do you have a laser printer? Yes
(13) Do have inter connectivity? BSNL

(In the absence of computer, printer and internet, the authorization will not be given)