ANDAMAN AND NICOBAR ADMINISTRATION DIRECTORATE OF SOCIAL WELFARE ........ APPLICATION FORM FOR GRANT OF UN-EMPLOYMENT ALLOWANCE TO HANDICAPPED 1. Name of Applicant : (Block letters) One Passport Size Photo 2. Father's Name : 3. Married/Unmarried/Widow : 4. Sex : 5. Date of Birth : 6. Identification marks : 7. Details of Physical & : mental infirmity 8. Permanent Address : 9. Present Address : 10. Qualification : 11. Employment Registration No. with : date of registration. 12. Category : 13. Caste : 14. Occupation : 15. Details of the members of the family including the applicant S.No Name Relationship Income Remarks 1. 2. 3. SIGNATURE OF THE APPLICANT CERTIFICATE TO BE FURNISHED FROM REVENUE AUTHORITY NOT BELOW THE RANK OF TEHSILDAR. Certified that Shri./ Smti/Miss ................... S/o, D/o.................... is a permanent resident of Andaman and Nicobar Islands for more than 10 years at the time of making this application. Signature Place : Name ............. Date : Designation ......... Office Seal .......... Contd.on..2.. : 2 : CERTIFICATE TO BE FURNISHED BY THE INVESTIGATOR Certified that the information furnished by Shri/Smt./Miss .... .................S/o, W/o/D/o ............ R/o ............... has been verified and found correct. Place : Signature of the Investigator Date : with date and Seal. Countersigned Sanctioned Director(Social Welfare) Secretary(Social Welfare) A&N Admn., Port Blair. A&N Admn., Port Blair. (Verification on Non-judicial stamp paper not less than Rs. 2/-). AFFIDAVIT I.............. S/o, W/o,D/o.............. ..............R/o .................. aged .........years for hereby solemnly affirm and declare that :- 1. The particulars given by me in the application are true to the best of my knowledge and belief. 2. I am not in receipt of any other financial assistance or grant from any other sources. 3. I will refund the entire amount of assistance to the Govt. in case the information furnished by me proves wrong at any time. Place : Date : (Deponent)
