Domicile Certificate Application Form

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E-governance initiative of …………… District

Court Fee Stamp of Rs.1.10

APPLICATION FOR DOMICILE CERTIFICATE (×F_tÝÌ^ç YÒ]çX Yy» [ýçã[ý %çã[ýVX) For recruitment in Army/ Central Para-Military Force/ Police only (åEõ¾_ éaXî [ýç×c÷XÝ/ åEõ³VÐÝÌ^ %ˆùÛ aç]×»Eõ [ýç×c÷XÝ/ %ç»lùÝ ×[ý\öçGTö ×X^Ç×Nþ» [ýçã[ý) 1. Name of Applicant 2. Age

(%çã[ýVXEõç»Ý» Xç])

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([ýÌ^a )

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3. Name of Father / Husband

(×YTöç/º¾ç]Ý» Xç]) :-

4. Name of Mother (]çTÊö» Xç] ):5. Permanent Address (ØšöçÌ^Ý ×PöEõXç ) :Village / Ward ____________________________ Town/ GP______________________________ (GçCg /¾çQïö ) (XG»/ GçCg Y‡ûçÌ^Tö ) Post Office ________________________________ Mouza _______________________________ (QöçEõH» ) (å]ìLç ) Revenue Circle ___________________________ Police Station____________________________ (»çLc÷ $JôyÔ) (UçXç) 6. Details of Land possessed by Applicant or his/her parents/ relatives:(%çã[ýVXEõç»Ý» [ýç åTöCg» %×\ö\öç¾Eõ» [ýç %ç±ÁÝÌ^» Xç]Tö UEõç \Çö×]» ×[ýTöe ×[ý¾»X) Mouza _________________ Village / Ward _________________________ (å]ìLç) (GçCg /¾çQïö ) Patta No._________________Dag No. _____________________________ (Yvôç Xe ) (VçG Xe ) I do hereby declare that the information furnished above is correct and true to the best of my knowledge and belief. ( ]+ åHçbXç Eõã»ç å^ CY»Tö =ä{×FTö aEõã_ç TöUî å]ç» pûçX %ç»Ó ×[ý¸¾ça ]ãTö £ˆù ) Date (Töç×»F ) :º¾çlù» )

Signature of the Applicant (%çã[ýVXEõç»Ý»

7.Gaonburah / Ward Commissioner’s Comments Applicant resides in my Village / Ward. (GçCg[ýÇRÍôç/¾çQïö Eõ×]$K÷Xç»» ]Ü™ö[ýî ) ( %çã[ýVXEõç»Ý å]ç» GçCg/ ¾çQïö» [ýç×a³Vç ) OfficeSeal (Eõç^ïîç_Ì^» å]çc÷» )

Date: (Töç×»F )

Signature of Gaon Burah/Ward Commissioner ( GçCg[ýÇRÍôç» / ¾çQïö Eõ×]$K÷Xç» º¾çlù» )

(For Office Use Only) Report of Circle Officer 1. Description of land as furnished by the applicant Is correct / incorrect :2. Up to date Land Revenue cleared / not cleared

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3. Since how many years the family of the applicant Is residing at the given address

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4. Recommended / Not Recommended

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Date: -

Signature and Name of Lot Mandal

5. Comment/ recommendation of Circle Officer

Seal of Office

Date: -

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Signature of Circle Officer

Receipt / Acknowledgement Application ID: DMC_________________

Date of Receipt: ________________

Service charge Rs. ____________________

Date of Delivery:________________

Signature of Receiving Assistant