eur LgdGlror$/ Self Declaration

sLSlTt rotr5!r-!-6, qorcwdlrfl orrrLb, Cleiror1gor--r4 dlrrnori,/ gsr;rir, f36 speq

oaior slnri:isndr GoL-@ 6)g19afloil o14l&96 6cdld| c&rflcn pleupugoir 6luuri $lg
e$pnor6 qgClu pneir, cre&orneir crgriouuuL- goorotaoir 34orar$,g;rb Dndr srdl$g
oraosdldt e;dnooo erorolLbrcr$g geelebsqgrb ooirorroir ooop6oure6lsbar:ar cranerlLb,
gnen aXafl$g psolabeot/ q5oraorirorir Ld.norLo6(9 qpLi:unauroror rror floirorrafl rit
OgdluorgLb ure$$ob, 0$$u gouruolorri er-t-tit 177 rofErb r99-on 61ir oor&6
er$rrne rr--urf$u.rnor gr-elrq&ane Go[61e noiraruu@ri: erdruop gxflGelcir creirg1
*u.rrf,loo or Gor r fil e-mr4lu.raflidlcirGmc&.

I am Selvi Sanmika daughter of Thiru Santhanam residing at Door No- 136, street of Vaaikal
[re[u Village / town of Chinnakumatli. Taluk of Bhuvanagiri, Cuddalore District, Tamil Nadu Srate
The details furnished by me are true to the best of my knowledge and believe and nothing has been
con(ealed herein. I declare that I am well aware of the fact that if the anformation and do(uments
given by me are proved 10 be incorrect / nor true in future, I shall be liable for prosecution under
section 177 & 199 ofthe lndian Penal Code.

(.krnrnikR
Signrture of the Appli.int / DglSrrnltr mar.luruuLD