CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & CIVIL SUPPLIES e-JAN SAMPARK Receipt no.________ Dated ____________ Please( ) whichever is applicable 1 Fresh 5 Addition of Member 2 Duplicate 6 Deletion of name of member 3 Replacement 7 Change of Address 4 Surrender 8 ________________________________________________________________________________ (FILL IN THE PARTICULARS IN BLOCK LETTERS) 1. Full name of the applicant Resi.Telephone no.________ 2. Father's /Husband's name 3. Complete Residential address i.e. House No. Sector/village/colony Chandigarh 4. In case of local change of address Sector/village/colony Chandigarh Previous address i.e. House no. 5. Occupation and full designation with address 6. Annual Family Income from all sources Rs. 6 (a) Place/State from where shifted with date of arrival 7. Full particulars of the persons for whom consumer card is required: GAS/KEROSENE User Sr.n Name (in block letters) Age Father's/Husband's name (in block letters) Relationship with the applicant Voter Identity Card No. Particulars of Additional deletion in column(b) (a) (b) (c) (d) (e) (f) (g) 1 2 3 4 5 6 7 8 9 10 e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 1 of 6 Space for Passport size family group photograph CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & CIVIL SUPPLIES e-JAN SAMPARK DECLARATION I here by solemnly declare that:- 1. Information given overleaf in form is correct. 2. Members included in column7 overleaf do(es) not draw specified food articles from Defence Forces or hold any consumer card in his/their name or any of the names mentioned overleaf, is/are not included in any other consumer card anywhere in India ( Certificate from Defence Authorities required in case of Defence personnel). 3. No member mentioned overleaf takes meals regularly in any Hostel/Boarding House. 4. I am a Kerosene/Gas user. (Gas agency .......... Consumer no...........) 5. I do not possess any gas connection of any oil company either in may name of the name of the name of any person. Further I do not possess any gas connection of an oil company belonging to any of my friend/acquaintance at my residence premises. 6. I and other members included in col.7 overleaf are likely to stay in Chandigarh permanently and are applying for Ration Card in Chandigarh for first time. 7. Ration card against which duplicate ration card has been applied for has actually been lost during the month_________________ 19 ______________________. In case it is traced out the same will be deposited in the Food & supplies Department U.T, Chandigarh and will not be ;used in any way. 8. The members mentioned in Column 7 overleaf are still residing at the given addresses and the names are the same as were in the lost card. 9. Two passport size family group photographs in respect of members mentioned in Column 7 overleaf are enclosed (one photograph is pasted overleaf). 10. Surrender/Deletion certificate issued by ____________________ is enclosed for the preparation of fresh ration card OR voter identity card of the Chandigarh Parliamentary Constituency in respect of major member and birth certificates in respect of minor members along with specified affidavit is enclosed. 11. Whether the applicant or any members of family mentioned in col.7 is an Income Tax Assecee or not, if yes write PAN Yes No Pan No Note 1: Applicant may please see instruction at page 3 Signature of Attesting person with seal Signature or thumb-impression of the applicant with date WARNING: APPLICANT GIVING FALSE INFORMATION AND PERSON ATTESTING THE APPLICATION FROM WRONG WILL RENDER THEMSELVES LIABLE TO CRIMINAL ACTION AS PROVIDED UNDER THE PROVISIONS OF THE CHANDIGARH HOARDING PREVENTION ORDER, 1977 PROMULGATED UNDER THE ESSENTIAL COMMODITIES ACT, 1955. ___________________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 2 of 6 CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & CIVIL SUPPLIES e-JAN SAMPARK INSTRUCTIONS FOR THE APPLICANT 1. Incomplete application form will be rejected. 2. The application form should be filled neatly with legible, writing. 3. In case of Fresh/Duplicate/Replacement of Ration Card, addition/deletion of units and change of address two passport size family group photographs in respect of members mentioned in column 7 at page 1 are to be enclosed. (One photograph to be pasted). 4. For fresh ration card, a surrender or deletion certificate, issued by the rationing authority from where the applicant has migrated be attached with the application form along with allotment letter in case of Govt. accommodation. OR Voter Identity Card of Chandigarh parliamentary constituency in respect of major members and birth certificates in case of minor member along with specified affidavit is to be enclosed. 5. In the applicant is a Government servant, he should get the application form attested from the head of the Office. If an applicant is not a government servant, he should get the application form attested from any Gazetted officer of the city or any other persona authorized by the Government. In case of Rural Area form be got attested from the Sarpanch of the Village. VERIFICATION/CANCELLATION REPORT OF DEPOT HOLDER/KEROSENE PUMP FOR THE ISSUANCE OF DUPLICATE RATION CARD/CHANGE OF ADDRESS/ISSUE OF SURRENDER CERTIFICATE Name of card holder Date on which last supplies issued Latest Registration no.of Ration card Unit Serial No. Code No. Authority No. & code No. of Fair Price Shop Depot holder Kerosene Pump ________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 3 of 6 CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & CIVIL SUPPLIES e-JAN SAMPARK Certified that I have cancelled the ration card of the applicant mentioned as page 1 from my Registration Register No. Quota will be issued against cancelled Ration card and if such card is produced with the Depot, I will deposit it in the office of the D.F. &S.O., U.T, Chandigarh. Signature of the Depot Holder/ K.Pump with code No. Stamp and Date ________________________________________________________________________________________ The above particulars i.e code No. and Serial No. have been Verified Fine Fee Receipt No of From D-IV Register for the issue of duplicate ration card. Duplicate Ration card With date__________________ Signature of Official with Code No. Stamp Signature of Official with Code No. Stamp ACKNOWLEDGMENT No.D-1/N ______________________ Date of Calling (if any) ____________________________ Name of applicant ______________________________________ address i.e H.No. __________________ Sector/village/colony _________________________ Chandigarh. Signature of Authorized Officer with Code No. Stamp ________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 4of 6 CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & CIVIL SUPPLIES e-JAN SAMPARK FOR OFFICE USE ONLY (Not to be filled by the applicant) Verification report of the Inspecting Official/Officer Verified today ................ And contacted Shri/Smt........ head of the family/other member/neighbored holder of Consumer Card No............ Registered with the Fair Price Shop No............ The particulars given in the application have been verified by me and found to be correct. Recommended for issue of permanent/duplicate distribution card in lieu of surrender Certificate/Lost card for ...... Minor,........ Ad jut,....... Total (unit, and registration of Ration Card with M\s ....................... The application is rejected on Account of the following reason/discrepancies noticed. 1................... 2 ..................... Signature of the inspector with date and Seal by Name Issued Card's Serial No......... Code No....... Entries of Fresh/Duplicate/Replacement of ration card/ Addition/Deletion of Units/Change of address and Surrender of Distribution Card have been made in the D-IV register. Signature of the Official Signature of the Official Signature of the Preparing the card with with code No. stamp distribution Card Code No. Stamp &Date who has made entry in the Issuing Authority with D-IV registers Code No. Stamp who Has signed the card e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 5 of 6 CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & CIVIL SUPPLIES e-JAN SAMPARK In case of incomplete form receipt in the office, application form is return in original for want of 1. Surrender/Deletion Certificate of Distribution 5. Allotment letter of govt.alloted Card Or Voter Identity card (certified copy of voter accommodation. List) of the Chandigarh Parliamentary constituency 6. Birth/Death Certificate Along with prescribed affidavit. 7. Incomplete Application Form 2. Form duly attested. 8. ............... 3. Two family group photographs. 4. Cancellation/Verification report of depot holder Signature of the Inspector with date and Seal AUTHORITY I hereby authorize Shri/Smt................ who is an adult member of my family to receive the consumer card on my behalf. Signature/Thumb-impression of the Applicant/ Head of the Family/card holder _______________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 6of 6
