(Constituted under the Act of Parliament No.

35 of 2002)

HAJ APPLICATION SET 1433 (H) - 2012

CLOSING DATE 16th APRIL, 2012.

(TO BE SUBMITTED TO CONCERNED STATE / UNION TERRITORY HAJ COMMITTEE ONLY)

PLEASE DO THE FOLLOWING :Read t p 1. Read the instrucions give n in the Haj a plication andguidelines before filling the Haj application form. filling plication form. One se tof Applica tion Form forTH REE appicant s only. If the cover contain more t han three a pplicants, then ano ther set of l 2. For m plicants, t hen ano Application Form is to b filled and attached toge ther. e The application form of each applicant shoud be filled in dupicate and in Engi sh BLOCK LETTERS with blue/black bal pen only. l l The e/black l 3. l Please dont use carbon. One set isfor SHC an another s for HCOI. ' d et Furnishcor rect name and other information as per international passport. 4. Latest 3.5cm X3.5cm passport size front posewith white background colour phoographs tobe pasted on ea h application form. t c 3.5cm 5. siz ite Deposit Rs.200/- per applica nt towards the non refundable processing fee in the Haj Committee of India Bank Account 6. No.32175017712 maintained with theState Bank ofIn da acoss various branches of the SBI having this facility. Use pay-in-slip r i pay-in-slip (Pink colour)atache dw ith this applicato nfor m. Attach t same withthe Ha j applcat ion form. Please note that no Bank Daft / t i i r he sam ew applicat Cashwill be acceped. t ashwillbe r 7. Photo copy of validInternational passpot duly self attested must be enclosed. 8. Photo copy of cancelled blank cheque of the applicant maybe enclosed (optional). 9. Copy of proof of addressofthe applicant must be enclosed. 10. No direct application should be sent to Haj Committee ofIndiaMumbai, If submitted itt will be treated as invalid foral purposes. Commi l p urposes. mitted 11. The la st date forsubmission of Haj appi cation form to the concerned State / UnionTerri tory Haj Committee is 16th April, 2012. l catio T t Commitee is t t r i 12. Applicaion Form received after expiry of the Closing Dae shall not be entetan ed. l m i t 13. Ask for Acknowe dgment from State Haj Com ittee onsubmisso n ofapplicaions. 14. Obain cove r number fom State Haj Committee. t cover r beobtained r i m t 15. The ApplicationF orms with Haj Guidelinesfor Haj 1433(H) 2012 can be obtained ff om the State/Union Terrtor y Haj Co mitee free j i of cost or c be downloaded from www.hacommtt ee.com. Photo copies can also beused. an

THIS FORM IS SUPPLIED FREE OF COST

DATES TO REMEMBER
Date
16.04.2012 11.06.2012 19.07.2012 31.07.2012 Last Date for submission of ... Haj Appllication Form with Pay-in-slip of Rs.200/- per applicant (Every applicant). Passport and Pay-in-slip of Rs.51,000/- per applicant (Selected pilgrims only). Payment of Balance Haj Amount and Air Fare (Selected pilgrims only). Allotment letter of Rubat (Selected pilgrims only).

(To BE FILLED BY PILGRIM)

HAJ - 1433 (H) - 2012

Acknowledgment
A).Recei ved the followingH aj appi cai on from Mr. l t
Sr. No. Name Sex Passport Number Head of Cover Co-pilgrim Co-pilgrim Co-pilgrim Co-pilgrim

(Cover Head)

Infant Infant
B. Received total applications = Adult ) Infant C).Cover number will be inom ed by State Haj Commtte e. f r i

Date :-

Seal

Signature of Secretary / Executive Officer State Haj Committee.

NOTE:- AFTER QURRAH INSTRUCTIONS ON THE REVERSE. (To be retained by pilgrim)

HAJ COMMITTEE OF INDIA

(Constituted under the Act of Parliament No. 35 of 2002)

HCOI COPY
(HAJ COMMITTEE OF INDIA)

DATE OF RECEIPT

APPLICATION FORM FOR HAJ - 1433 (H) - 2012 FOR OFFICE USE ONLY SEATS SERIAL NO. COVER NUMBER
ADULT

Photo of the applicant

INFANT

Embarkation Point:1. APPLIED FOR: (i) Reserved Category (a). 70+ Category (Give details of Companion):

SERIAL NUMBER OF HCOI

(ii) General Category (Tick the appropriate () (Please refer Guidelines and Instructions)

Companion Full Name Relationship (b). Fourth Time Applicants (Give rejected cover numbers of last 3 years ): Year 2009 Cover No. Year 2010 Cover No.

Paste your recent passport size colour photograph having WHITE BACKGROUND (Size:3.5 x 3.5 cms)

Year 2011 Cover No.

2. NAME OF THE HEAD OF THE COVER (MALE ONLY) 3. ACCOMMODATION STATUS : Tick the desired category () GREEN* AZIZIA*

4. APPLICANT BIO DATA (AS PER INTERNATIONAL PASSPORT) Details of International Passport. (Photo copy of valid International passport duly self attested must be attached) Passport Number Date of Issue Applicant:- Surname Given Name Father's Full Name Mother's Name Present Residential Address, Including Street No. with PIN code Spouse Name Place of Issue Date of Expiry

PIN CODE District (i) Mobile No. SEX Male / Female Occupation :Date of Birth (ii) Mobile No.Nationality - INDIAN EDU. QUALIFICATION. Place of Birth State Tel No.MARITAL STATUS - Married / Unmarried

Age -

5. NAME & RELATION OF NOMINEE OR LEGAL REPRESENTATIVE OF APPLICANT:Full Name Father / Husband Name Relationship Address Pin Code District Name Relationship International Passport Number of Mehram State

(particulars of the person declared as nominee in India who should be contacted in case of exigencies in India/Saudi Arabia)

Telephone/Mobile No.

Signature / Thumb Impression of Nominee

6. NAME OF MEHRAM WITH RELATION (for female pilgrims only) (Photo copy of valid International passport to be attached)

Signature / Thumb Impression of Mehram

7. DETAILS REQUIRED FOR REFUND, IF ANY (Please provide the account number and a photo copy of cheque should be attached) Branch code Account No. Name of the Bank Name of the Branch IFS Code MICR Code 8. Details of non refundable processing fee Rs.200/- per pilgrim deposited. (The pink colour pay-In-slip should be attached) Amount Branch Code No. Name of Branch Receipt Date

9. MEEQAT FOR SHIA PILGRIMS:JOHFA Yes No I certify that I have gone through the guidelines of Haj 1433 (H) 2012 and I undertake to abide by the same.

SIGNATURE/ THUMB IMPRESSION OF THE APPLICANT

ENCLOSURES: Tick the relevant 1. Proof of Address - Attach Photo copy of any one of the following:
(a) Ration Card (b) Driving License (c) Electricity Bill (d) Telephone Bill (Land Line) (e) Voter's Identity Card

2. 5.

Copy of valid International passport (self attested) Affidavit (for Reserved Categories only)

3.

Copy of cancelled blank cheque

4.

Pay-in-slip

SOLEMN DECLARATION / UNDERTAKING BY THE APPLICANT

I ____________________________________ s/o, w/o, d/o. _________________________________________________ resident of ____________________________________________________________________________ (in block letters) do hereby solemnly declare and affirm that:1. 2. I am an Indian National and a Muslim intending to perform Haj 1433 (H) 2012 and that I have not performed Haj during the last five years viz. 2007 to 2011, through Haj Committee of India. Haj Committee of India is an organization constituted under the Act of Parliament rendering its services freely to the Haj Pilgrims. Hence it does not come under the purview of Consumer Protection Act of 1986. I therefore, have no right to claim any compensation against Haj Committee of India under the above Act. The Courts of Greater Mumbai only shall exercise Jurisdiction in all matters of dispute. I am aware that attending training / orientation camps to understand the entire Haj is in my own interest and I undertake to attend the same and provide my training details in the Health and Training (HAT) Card before proceeding for Haj at the Embarkation point. I am aware of the topography of Makkah Mukarrama & Madinah Munawwarah and the difficulties Pilgrims face during the Haj period in respect of accommodation, transport etc. and that rules, regulations and laws of Kingdom of Saudi Arabia are beyond the control of Haj Committee of India. Hence I will not blame the Haj Committee of India for any inconvenience caused to me on account of this or on account of any acts of commission or omission by me. I have no objection if accommodation category is changed by Haj Committee of India in case of dire necessity, non-availability and I accept the difference of refund or payment of excess as the case may be. I am aware that my space entitlement in Makkah and Madinah accommodation is 4 square meter per person. I am also aware that pilgrims are accommodated in Makkah and Madinah based on the license issued by Saudi Authorities. I am aware that I should share the room, kitchen facilities, toilets and wash room facilities with other pilgrims. I understand that I will have to travel as per allotment made by the Haj Committee of India, Mumbai and I am not entitled to get it changed as a matter of right. I further understand that in case of cancellation of travel by me the Haj Committee of India, Mumbai is entitled to levy the penalty as per norms laid down in the Guidelines for Haj 1433 (H) 2012. I am aware that my stay in Saudi Arabia may be 30 to 40 days depending on schedule given by Airlines. I am aware that Makkah accommodation is hired for entire Haj season and not on day basis and I am not entitled for any refund based on duration of stay. I hereby authorize Haj Committee of India to obtain on my behalf the Foreign Exchange in Riyals, and pay me after deducting dues, if any. I know it is my bounden duty and responsibility to submit my valid International passport in time to the Haj Committee of India for processing my application for visa etc., failing which, Haj seat allotted to me will automatically get cancelled without any intimation to me. I will strictly comply with the rules laid down with regard to standard baggage i.e. Two suitcase of 158 cm (L-75 + B-55 + H-28) 22 kgs. each and one handbag of 10 Kgs. measuring 22 x 16 x 8 suitable for keeping in the rack overhead or under the passenger seat. I affirm and declare that I am not suffering from any disease communicable or otherwise or disability or mental disorder whatsoever, which might impede or jeopardize my Haj. No court order prohibiting me from proceeding for Haj is existing. In case of death, due to natural causes or accident during the Haj period, burial and rituals may be performed as per the prevailing practice in Kingdom of Saudi Arabia in my case also. I further solemnly affirm and declare that in case of suppression of material information or giving false and incorrect declaration/undertaking by me, I stand to forfeit the amount deposited by me with the Haj Committee of India and prosecution proceedings may be initiated against me. I hereby authorize Haj Committee of India to send SMS even though my number is under DND register. I declare that I have read the guidelines issued for Haj 1433 (H) 2012 and the particulars given by me in this Application Form, declaration/undertaking are true and correct to the best of my knowledge.
___________________________________________________

3. 4.

5.

6.

7. 8. 9. 10. 11. 12. 13. 14. 15.

Signature / Thumb Impression of the Applicant

MEDICAL SCREENING AND FITNESS CERTIFICATE
FULL NAME DATE OF BIRTH: Female GENDER: Male Blood Group: PAST MEDICAL HISTORY (i) NERVOUS SYSTEM Asthma Yes /No If yes, when detected _________________________________ Any loss of consciousness/ Yes / No Current treatment ____________________________________ If yes, date of incident __________________________________ Current treatment ______________________________________ Allergies Yes /No Any paralysis? Yes / No If yes, date of last reaction _____________________________ If yes, state deficiency___________________________________ Cause of reaction ____________________________________ When acquired________________________________________ Current treatment______________________________________ Major Surgeries Yes /No If yes, type of surgery _________________________________ Any fits? Yes /No Date of surgery ______________________________________ If yes, type of fits_______________________________________ Outcome of surgery ___________________________________ Date of last episode____________________________________ Current treatment______________________________________ Hypertension/BP Yes /No If yes, when detected _________________________________ (ii) MUSCULO-SKELETAL SYSTEM Current treatment ____________________________________ Any Deformity/Unable to walk? Yes / No If yes, which part of the body______________________________ Any Heart Dissease/Bypass surgery done?Yes /No When acquired_________________________________________ If yes, what disease? __________________________________ Use of accessories or aids________________________________ Current treatment _____________________________________ (iii) OTHER CHRONIC CONDITIONS Diabetes Mellitus Yes /No Any Heart Dietary Restrictions Yes /No If yes, when detected____________________________________ If yes, state restriction ____________________ Current Status_________________________________________ Tuberculosis (TB) Yes /No BLOOD If yes, when detected____________________________________ High Low Normal PRESSURE () Current Status Cured / On going treatment___________________

This is to certify that above pilgrim is physically fit to undertake Haj journey.

Name of th Doctor ________________________________

Registered No. ___________________

Signature / Thumb Impression of Applicant

Verified by Registered Medical Practioner with complete address & Signature

(FOR OFFICIAL USE ONLY) Checked by Name (SHC) __________________________________________

Signature / Date Signature / Date

Data Entry Done (SHC) ____________________________________________

The State Haj Committee shall ensure that no repeater's Haj Application is entertained and endorsed to Haj Committee of India.
A). The entries in respect of Domicile, Permanent Address, Medical Screening Form-Cum-Fitness Certificate have been checked and found in order. It is certified that the Applicant is eligible to register for Haj-1433 (H) 2012 under this state Quota. B). The application is selected in Qurrah/as per priority waiting against cancellation/additional quota and submitted passports, photo copy of bank Pay-in-slip for initial payment. The data entries have already been done and forwarded to Haj Committee of India, Mumbai for further necessary action.

Executive Officer / Secretary,

State Haj Committee

HAJ COMMITTEE OF INDIA

(Constituted under the Act of Parliament No. 35 of 2002)

SHC COPY
(STATE HAJ COMMITTEE)

DATE OF RECEIPT

APPLICATION FORM FOR HAJ - 1433 (H) - 2012 FOR OFFICE USE ONLY SEATS SERIAL NO. COVER NUMBER
ADULT

Photo of the applicant

INFANT

Embarkation Point:1. APPLIED FOR: (i) Reserved Category (a). 70+ Category (Give details of Companion):

SERIAL NUMBER OF HCOI

(ii) General Category (Tick the appropriate () (Please refer Guidelines and Instructions)

Companion Full Name Relationship (b). Fourth Time Applicants (Give rejected cover numbers of last 3 years ): Year 2009 Cover No. Year 2010 Cover No.

Paste your recent passport size colour photograph having WHITE BACKGROUND (Size:3.5 x 3.5 cms)

Year 2011 Cover No.

2. NAME OF THE HEAD OF THE COVER (MALE ONLY) 3. ACCOMMODATION STATUS : Tick the desired category () GREEN* AZIZIA*

4. APPLICANT BIO DATA (AS PER INTERNATIONAL PASSPORT) Details of International Passport. (Photo copy of valid International passport duly self attested must be attached) Passport Number Date of Issue Applicant:- Surname Given Name Father's Full Name Mother's Name Present Residential Address, Including Street No. with PIN code Spouse Name Place of Issue Date of Expiry

PIN CODE District (i) Mobile No. SEX Male / Female Occupation :Date of Birth (ii) Mobile No.Nationality - INDIAN EDU. QUALIFICATION. Place of Birth State Tel No.MARITAL STATUS - Married / Unmarried

Age -

5. NAME & RELATION OF NOMINEE OR LEGAL REPRESENTATIVE OF APPLICANT:Full Name Father / Husband Name Relationship Address Pin Code District Name Relationship International Passport Number of Mehram State

(particulars of the person declared as nominee in India who should be contacted in case of exigencies in India/Saudi Arabia)

Telephone/Mobile No.

Signature / Thumb Impression of Nominee

6. NAME OF MEHRAM WITH RELATION (for female pilgrims only) (Photo copy of valid International passport to be attached)

Signature / Thumb Impression of Mehram

7. DETAILS REQUIRED FOR REFUND, IF ANY (Please provide the account number and a photo copy of cheque should be attached) Branch code Account No. Name of the Bank Name of the Branch IFS Code MICR Code 8. Details of non refundable processing fee Rs.200/- per pilgrim deposited. (The pink colour pay-In-slip should be attached) Amount Branch Code No. Name of Branch Receipt Date

9. MEEQAT FOR SHIA PILGRIMS:JOHFA Yes No I certify that I have gone through the guidelines of Haj 1433 (H) 2012 and I undertake to abide by the same.

SIGNATURE/ THUMB IMPRESSION OF THE APPLICANT

ENCLOSURES: Tick the relevant 1. Proof of Address - Attach Photo copy of any one of the following:
(a) Ration Card (b) Driving License (c) Electricity Bill (d) Telephone Bill (Land Line) (e) Voter's Identity Card

2. 5.

Copy of valid International passport (self attested) Affidavit (for Reserved Categories only)

3.

Copy of cancelled blank cheque

4.

Pay-in-slip

SOLEMN DECLARATION / UNDERTAKING BY THE APPLICANT

I ____________________________________ s/o, w/o, d/o. _________________________________________________ resident of ____________________________________________________________________________ (in block letters) do hereby solemnly declare and affirm that:1. 2. I am an Indian National and a Muslim intending to perform Haj 1433 (H) 2012 and that I have not performed Haj during the last five years viz. 2007 to 2011, through Haj Committee of India. Haj Committee of India is an organization constituted under the Act of Parliament rendering its services freely to the Haj Pilgrims. Hence it does not come under the purview of Consumer Protection Act of 1986. I therefore, have no right to claim any compensation against Haj Committee of India under the above Act. The Courts of Greater Mumbai only shall exercise Jurisdiction in all matters of dispute. I am aware that attending training / orientation camps to understand the entire Haj is in my own interest and I undertake to attend the same and provide my training details in the Health and Training (HAT) Card before proceeding for Haj at the Embarkation point. I am aware of the topography of Makkah Mukarrama & Madinah Munawwarah and the difficulties Pilgrims face during the Haj period in respect of accommodation, transport etc. and that rules, regulations and laws of Kingdom of Saudi Arabia are beyond the control of Haj Committee of India. Hence I will not blame the Haj Committee of India for any inconvenience caused to me on account of this or on account of any acts of commission or omission by me. I have no objection if accommodation category is changed by Haj Committee of India in case of dire necessity, non-availability and I accept the difference of refund or payment of excess as the case may be. I am aware that my space entitlement in Makkah and Madinah accommodation is 4 square meter per person. I am also aware that pilgrims are accommodated in Makkah and Madinah based on the license issued by Saudi Authorities. I am aware that I should share the room, kitchen facilities, toilets and wash room facilities with other pilgrims. I understand that I will have to travel as per allotment made by the Haj Committee of India, Mumbai and I am not entitled to get it changed as a matter of right. I further understand that in case of cancellation of travel by me the Haj Committee of India, Mumbai is entitled to levy the penalty as per norms laid down in the Guidelines for Haj 1433 (H) 2012. I am aware that my stay in Saudi Arabia may be 30 to 40 days depending on schedule given by Airlines. I am aware that Makkah accommodation is hired for entire Haj season and not on day basis and I am not entitled for any refund based on duration of stay. I hereby authorize Haj Committee of India to obtain on my behalf the Foreign Exchange in Riyals, and pay me after deducting dues, if any. I know it is my bounden duty and responsibility to submit my valid International passport in time to the Haj Committee of India for processing my application for visa etc., failing which, Haj seat allotted to me will automatically get cancelled without any intimation to me. I will strictly comply with the rules laid down with regard to standard baggage i.e. Two suitcase of 158 cm (L-75 + B-55 + H-28) 22 kgs. each and one handbag of 10 Kgs. measuring 22 x 16 x 8 suitable for keeping in the rack overhead or under the passenger seat. I affirm and declare that I am not suffering from any disease communicable or otherwise or disability or mental disorder whatsoever, which might impede or jeopardize my Haj. No court order prohibiting me from proceeding for Haj is existing. In case of death, due to natural causes or accident during the Haj period, burial and rituals may be performed as per the prevailing practice in Kingdom of Saudi Arabia in my case also. I further solemnly affirm and declare that in case of suppression of material information or giving false and incorrect declaration/undertaking by me, I stand to forfeit the amount deposited by me with the Haj Committee of India and prosecution proceedings may be initiated against me. I hereby authorize Haj Committee of India to send SMS even though my number is under DND register. I declare that I have read the guidelines issued for Haj 1433 (H) 2012 and the particulars given by me in this Application Form, declaration/undertaking are true and correct to the best of my knowledge.
___________________________________________________

3. 4.

5.

6.

7. 8. 9. 10. 11. 12. 13. 14. 15.

Signature / Thumb Impression of the Applicant

MEDICAL SCREENING AND FITNESS CERTIFICATE
FULL NAME DATE OF BIRTH: Female GENDER: Male Blood Group: PAST MEDICAL HISTORY (i) NERVOUS SYSTEM Asthma Yes /No If yes, when detected _________________________________ Any loss of consciousness/ Yes / No Current treatment ____________________________________ If yes, date of incident __________________________________ Current treatment ______________________________________ Allergies Yes /No Any paralysis? Yes / No If yes, date of last reaction _____________________________ If yes, state deficiency___________________________________ Cause of reaction ____________________________________ When acquired________________________________________ Current treatment______________________________________ Major Surgeries Yes /No If yes, type of surgery _________________________________ Any fits? Yes /No Date of surgery ______________________________________ If yes, type of fits_______________________________________ Outcome of surgery ___________________________________ Date of last episode____________________________________ Current treatment______________________________________ Hypertension/BP Yes /No If yes, when detected _________________________________ (ii) MUSCULO-SKELETAL SYSTEM Current treatment ____________________________________ Any Deformity/Unable to walk? Yes / No If yes, which part of the body______________________________ Any Heart Dissease/Bypass surgery done?Yes /No When acquired_________________________________________ If yes, what disease? __________________________________ Use of accessories or aids________________________________ Current treatment _____________________________________ (iii) OTHER CHRONIC CONDITIONS Diabetes Mellitus Yes /No Any Heart Dietary Restrictions Yes /No If yes, when detected____________________________________ If yes, state restriction ____________________ Current Status_________________________________________ Tuberculosis (TB) Yes /No BLOOD If yes, when detected____________________________________ High Low Normal PRESSURE () Current Status Cured / On going treatment___________________

This is to certify that above pilgrim is physically fit to undertake Haj journey.

Name of th Doctor ________________________________

Registered No. ___________________

Signature / Thumb Impression of Applicant

Verified by Registered Medical Practioner with complete address & Signature

(FOR OFFICIAL USE ONLY) Checked by Name (SHC) __________________________________________

Signature / Date Signature / Date

Data Entry Done (SHC) ____________________________________________

The State Haj Committee shall ensure that no repeater's Haj Application is entertained and endorsed to Haj Committee of India.
A). The entries in respect of Domicile, Permanent Address, Medical Screening Form-Cum-Fitness Certificate have been checked and found in order. It is certified that the Applicant is eligible to register for Haj-1433 (H) 2012 under this state Quota. B). The application is selected in Qurrah/as per priority waiting against cancellation/additional quota and submitted passports, photo copy of bank Pay-in-slip for initial payment. The data entries have already been done and forwarded to Haj Committee of India, Mumbai for further necessary action.

Executive Officer / Secretary,

State Haj Committee

(To deposit Rs.200/- per pilgrim and maximum of Rs.1,000/- only) State Bank of India
Branch:Code:-

BANK COPY
(BRANCH COPY)

HAJ COMMITTEE OF INDIA

HAJ 1433 (H) - 2012

Can be tendered at any State Bank of India Branch

SBI-SWO-PLEASE ENTER PASSPORT NO. IN SBI REF. NO. IN FIELD AND WRITE TRANSACTION-ID(JRL NO.) ON ALL COPIES OF CHALLAN

COLLECTION - DETAILS
ACCOUNT NUMBER : 32175017712 SBI REFERENCE NO. / PASSPORT NUMBER OF MAIN APPLICANT Name of the Head of Cover : - 2012 Deposited Date : PARTICULARS OF THE PAYMENT :
SR. NO. NAME OF THE PILGRIM

Mobile Number
CASH NOTE AMOUNT IN RS. = = = = = = =

ADDRESS OF HEAD OF COVER

Amount (In words) Rupees

x 1000 x 500 x 100 x 50 x 20 x 10 x 5 Total Rs.

Transaction ID (Bank Journal No.)

Branch Stamp with Signature Deposited by

COPY - HAJ COMMITTEE OF INDIA

Haj House, 7-A, M. R. A. Marg (Palton Road), Mumbai - 400 001.

State Bank of India

Branch:Code:-

HCOI COPY
(HAJ COMMITTEE OF INDIA)

HAJ COMMITTEE OF INDIA

HAJ 1433 (H) - 2012

Can be tendered at any State Bank of India Branch

SBI-SWO-PLEASE ENTER PASSPORT NO. IN SBI REF. NO. IN FIELD AND WRITE TRANSACTION-ID(JRL NO.) ON ALL COPIES OF CHALLAN

COLLECTION - DETAILS
ACCOUNT NUMBER : 32175017712 SBI REFERENCE NO. / PASSPORT NUMBER OF MAIN APPLICANT Name of the Head of Cover : - 2012 Deposited Date : PARTICULARS OF THE PAYMENT :
SR. NO. NAME OF THE PILGRIM

Mobile Number
CASH NOTE AMOUNT IN RS. = = = = = = =

ADDRESS OF HEAD OF COVER

Amount (In words) Rupees

x 1000 x 500 x 100 x 50 x 20 x 10 x 5 Total Rs.

Transaction ID (Bank Journal No.)

Branch Stamp with Signature Deposited by

State Bank of India

Branch:Code:-

PILGRIM COPY

HAJ COMMITTEE OF INDIA

HAJ 1433 (H) - 2012

Can be tendered at any State Bank of India Branch

SBI-SWO-PLEASE ENTER PASSPORT NO. IN SBI REF. NO. IN FIELD AND WRITE TRANSACTION-ID(JRL NO.) ON ALL COPIES OF CHALLAN

COLLECTION - DETAILS
ACCOUNT NUMBER : 32175017712 SBI REFERENCE NO. / PASSPORT NUMBER OF MAIN APPLICANT Name of the Head of Cover : - 2012 Deposited Date : PARTICULARS OF THE PAYMENT :
SR. NO. NAME OF THE PILGRIM

Mobile Number
CASH NOTE AMOUNT IN RS. = = = = = = =

ADDRESS OF HEAD OF COVER

Amount (In words) Rupees

x 1000 x 500 x 100 x 50 x 20 x 10 x 5 Total Rs.

Transaction ID (Bank Journal No.)

Branch Stamp with Signature NOTE: Photo copy of pay-in-slip may also be used for deposit of amount Deposited by

If any difficulty, please contact: State Bank of India, Mumbai Main Branch - Mobile No.09930766530