CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & SUPPLY e-JAN SAMPARK CHANDIGARH ADMINISTRATION FOOD AND SUPPLIES DEPARTMENT U.T., CHANDIGARH Form B.P.L D-1 1. Full name of the applicant 2. Father's/Husband's name Sector/Village/Colony Chandigarh 3. (i) Complete Residential Address i.e House no. 3 (ii) Old Address House no. _____________ Sector/Village/Colony__________Chandigarh 3 (iii) Place from where shifted to Address Date Chandigarh with date 4. Are you living in - (i) Kacha/Pacca House/Tenement __________________________________ (ii) Jhuggi Jhopri Colony __________________________________ (iii) Labour Colony __________________________________ (iv) Since when are you living __________________________________ 5. Occupation and Address of the Office/Place Of business/work ______________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 1 of 4 6. Are you working as- [ ( ) whichever is applicable] (i) Landless Agricultural Labourer [ ] (ii) Potter [ ] (iii) Weaver [ ] (iv) Blacksmith [ ] (v) Carpenter [ ] (vi) Collie [ ] (vii) Rickshaw Puller [ ] (viii) Hand Cart Puller [ ] (ix) Fruit/vegetable/Flower Seller/Hawker at pavement [ ] (x) Any other trade [ ] 7. Annual family income from all sources 8. Whether belongs to {Please ( ) whichever is applicable} - (i) Schedule caste (ii) Schedule tribe DECLARATION I, the above named applicant, do hereby solemnly affirm and declare that the above information given by me is true and correct to the best of my knowledge and belief and nothing has been concealed therein. Signature or thumb-impression of the applicant with date RECOMMENDATION BY THE COUNCIL/SARPANCH Certified that I have satisfied myself that the information given is correct and I have checked that the applicant does not possess any property including moveable property like Refrigerator, Television, Moped etc. and that he is below the Poverty line. Recommended for the issue of TARGETTED PUBLIC DISTRIBUTION CARD Place: Date: Signature of the Councilors/Sarpanch(Seal) WARNING: APPLICANT GIVING FALSE INFORMATION AND PERSON ATTESTING THE APPLICATION FORM WRONG WILL RENDER THEMSELVES LIABLE TO CRIMINAL ACTION AS PROVIDED UNDER THE ESSENTIAL COMMODITIES ACT, 1955 ________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 2 of 4 (Detail of family members for below Poverty Line card) 9. Full particulars of the persons for whom BPL card is required. Signature or thumb impression of the applicant ______________________________________________________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 3 of 4 FOR OFFICE USE ONLY (Not to be filled by the applicant) Verified today........... and contacted Shri/Smt........... head of the family/other member neighbourer, 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 TARGETED PUBLIC DISTRIBUTION CARD/AUTHORISED CARD.______________________________________________ The application is not verified on Account of the following reasons/discrepancies noticed 1................... 2.................. Signature of the Inspector with date and Seal by Name On the basis of the recommendation of the concerned Councilors/Sarpanch and verification report of Inspector Food and Supplies/Gr.II, Ration Card/Authorization Card Sr. No........... Issued under the Targeted Public Distribution System Scheme. Signature of the Inspector with date and Seal by Name 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 : 4of 4 (FILL IN THE PARTICULARS IN BLOCK LETTERS) Do you possess Ration Card? Yes/No PARTICULARS OF DISTRIBUTIONS CARD IN POSSESSION OF THE APPLICANT Card No.______________ Sr. No. ____________________ Date of Issue ______________ Total units of Fair Price Shop where Regd. With________________ Distributions Card _______________ Registration No. ________________________ CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & SUPPLY e-JAN SAMPARK CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & SUPPLY e-JAN SAMPARK Sr.No Name (in Block letters) Age Father's/Husband name Relationship with the applicant Passport size family group photograph CHANDIGARH ADMINISTRATION DEPARTMENT OF FOOD & SUPPLY e-JAN SAMPARK
