Their is no specified form. you have to write a application in your own hand writing in english or hindi language (medium opted in examination) clearly indicating subjects to be verified, roll no.. And application must be signed by the candidate.And don't give any contact number in application.
There is no standard format given to apply for verification. The fee per subject is INR 100. Further details you can had from below link, which sets out the procedure as given in previous verification notification. We hope it will be same even now, as no new notification for verification announced yet.