APPLICATION FOR ADMISSION INTO SERVICE HOME ANNEXURE - I (a) (to G.O.Ms.No.66 of WD, CW & (See Rule 8) DW (Prog.) Department) FORM OF APPLICATION FOR ADMISSION INTO SEVA SADAN 1. Name in full (in Block Letters) : 2. Full Address : 3. Date of Birth and Age : 4. Caste & Religion (State whether SC / ST / BC Classes) : 5. Name of Guardian, Nature of relationship to the applicant, occupation and income : 6. Whether candidate is unmarried or married or widow or deserted; if deserted a certificate of separation from the husband should be furnished, where this is not possible a certificate from a responsible person who will guarantee that the husband will not interfere with her stay in the Home should be furnished : 7. If married or widowed, whether she has any children; their ages and whether they are living with her : 8. General educational attainments : 9. Reasons for seeking admission : 10. Whether she possesses any movable or immovable property. If so it's value (income certificate be enclosed). : 11. Whether any case relating to her is pending in court : 12. Whether she has been employed (give details) : 13. Name of three persons with full addresses who will be visiting her in the event of her admission : I declare that the particulars furnished above are correct to my knowledge and belief. I also declare that if I am selected I shall abide by all the rules of the Home and shall endeavor my best to prove myself satisfactory in every way. DATE:-SIGNATURE OF APPLICANT CERTIFICATE TO BE FURNISHED BY THE GUARDIAN I declare that I am the guardian of the above candidate and that the particulars furnished above are correct. I also declare that I shall take her back after 3 years or on completion of training which ever is earlier or if she is discharged on medical grounds or for misbehaviour. SIGNATURE OF GUARDIAN DATE: PLACE:
