PART-I

1. Name of the Applicant :

2. Gender: Male/Female :

3. Father’s/Mother’s full name :

4. Address for correspondence (with Pin Code) :

5. Telephone/Mobile No. and E-mail ID (if, any) :

PART-II

(i) Specify the particulars of the information sought for in a separate sheet

(ii) Whether the information sought for is required to be supplied

          (a) In printed form.

          (b) In diskette or floppy.

(iii) Whether inspection of records also sought

(iv) Whether application fee of Rs.10/- (Rupees ten only) paid and, if so, please specify mode of payment.

         (a) Please give details of the demand draft/Banker’s cheque enclosed.

         (b) In case of cash payment, please enclose original receipt.
         (No fee is required to be paid if the requester belongs to ‘below poverty line’ category for     which proof should be furnished).

Declaration of the Applicant

I am a bonafide citizen of India and owe allegiance to the sovereignty, unity and integrity of India and have not voluntarily acquired the citizenship of another country.

Place :

(Signature of the applicant)

Date :