Pardeep
๑۩۩๑┼●ℛŐŶ
NOTE: If you dont know the answers, please capi fram another applikason pharum and submit. For further instruktions, see battum
applikason.
Please do not shoot the person at the applikason kounter. He will give
you the lisen immediately.
(Check appropriate box)
Last name:
(_) Yadav
(_) Sinha
(_) Pandey
(_) Mishra
(_) do not know
First name:
(_) Ramprasad
(_) Lakhan
(_) Sivaprasad
(_) Jamnaprasad
(_) Dont know
Age:
(_) Less than zero
(_) Zero
(_) Greater than zero
(_) Don't know
Sex:
____ M _____ F _____ not sure _____ not applicable
Chappal Size:
____ Left ____ Right
Occupasion:
(_) Politician
(_) Doodhwala
(_) Pehelwaan
(_) House wife
(_) Un-employed
Number of children living in household:
___
Number tha t are yours: ___
Mother\'s Name: _______________________
Father\'s Name: _______________________
(If not sure, leave blank)
Ejjucason:
1 2 3 4 (Circle highest grade completed)
Do you bathe?
(_) Yes (_) No Not applicable
If yes, how often do you bathe?
(_) Weekly
(_) Monthly
(_) Yearly
Color of teeth:
(_) Yellow
(_) Brownish-Yellow
(_) Brown
(_) Black
(_) Others - Give exact color (call nearest Asian Paints dealer if U
dont know the color of your teeth)
How far is your home from a paved road?
(_)1 mile (_)2 miles (_)don\'t know
_________________________
(Your thumb imparesson)
....contd....
applikason.
Please do not shoot the person at the applikason kounter. He will give
you the lisen immediately.
(Check appropriate box)
Last name:
(_) Yadav
(_) Sinha
(_) Pandey
(_) Mishra
(_) do not know
First name:
(_) Ramprasad
(_) Lakhan
(_) Sivaprasad
(_) Jamnaprasad
(_) Dont know
Age:
(_) Less than zero
(_) Zero
(_) Greater than zero
(_) Don't know
Sex:
____ M _____ F _____ not sure _____ not applicable
Chappal Size:
____ Left ____ Right
Occupasion:
(_) Politician
(_) Doodhwala
(_) Pehelwaan
(_) House wife
(_) Un-employed
Number of children living in household:
___
Number tha t are yours: ___
Mother\'s Name: _______________________
Father\'s Name: _______________________
(If not sure, leave blank)
Ejjucason:
1 2 3 4 (Circle highest grade completed)
Do you bathe?
(_) Yes (_) No Not applicable
If yes, how often do you bathe?
(_) Weekly
(_) Monthly
(_) Yearly
Color of teeth:
(_) Yellow
(_) Brownish-Yellow
(_) Brown
(_) Black
(_) Others - Give exact color (call nearest Asian Paints dealer if U
dont know the color of your teeth)
How far is your home from a paved road?
(_)1 mile (_)2 miles (_)don\'t know
_________________________
(Your thumb imparesson)
....contd....
Nxt Page
....contd..
* If you are capying from another applikason pharom, please do nat
capy thumb impression also.
* Please provide your own thumb impression.
PLEASE DO NAT USE FINGERS OF YOUR LEGS. Use thumb on your
lefthand only. If you dont have
left hand, use your thumb on right hand.
If
you do nat have right
hand,
use thumb on left hand.
NOTE : IF YOU DONT HAVE BOTH HANDS, YOU
CANNOT DRIVE
>haha
* If you are capying from another applikason pharom, please do nat
capy thumb impression also.
* Please provide your own thumb impression.
PLEASE DO NAT USE FINGERS OF YOUR LEGS. Use thumb on your
lefthand only. If you dont have
left hand, use your thumb on right hand.
If
you do nat have right
hand,
use thumb on left hand.
NOTE : IF YOU DONT HAVE BOTH HANDS, YOU
CANNOT DRIVE
>haha
..
