Documente Academic
Documente Profesional
Documente Cultură
Photo
Da man /Diu.
1.
2.
Age
Relation
Sanjivani Swasthya
Bima Yojana
Card No.
1
2
3
4
5
6
7
8
9
10
7.
8.
House No.
(As per house Registration with village
Pancha at/ Municipal Corporation )
(a) Are you residing in rented house ?
(Attach rent agreement )
(b) Are you staying in a house
allotted by company. ? (Attach Proof)
(a) Are you a resident of Daman/Diu ?
(Attach Proof)
(b) Are you a resident of other state ?
If yes which state ?
(c) Do you have LPG Gas Connection
(d) How many Gas Cylinders do you
have. ?
Yes
No
Yes
No
Yes
Yes
No
No
Yes
No
Aadhar No. /
NPR No.
9.
Yes
No
10
Yes
No
Yes
No
Yes
No
12.
13.
15.
No
2008).(Attach Proof)
16.
17.
18.
19.
20.
21.
22.
23.
Rag
Pickers
Fishermen
Casual
daily
wages
labourers
Small
household
Casual
domestic
laborers
Enterprise/
unskilled
workers
Disabled
persons
Yes
Yes
Unskilled
Construction
Workers
Cycle
rickshaw
drivers
Household
industries
Unskilled
workers
Sweepers/
Sanitation
workers
No
No
Rs. /Yes
No
Yes
No
Grade Pay Rs.
Yes
No
Group of Post.
Grade Pay Rs.
Yes
No
Group of Post.
Place :
Date:
Porters
DECLARATION
I know that to make any false declaration is an offence and liable for penalty and cancellation of
Ration Card.
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