Regn. No. ......... Circle No. ......... Date of Receipt . . . . . . . . . . . . Date of Calling (if any) . . . . . . Form No.1 Application for new consumer card/duplicate Consumer Card/and revalidation of consumer card Warning :- Furnishing of false and incorrect information or suppression of any material information is an offence punishable with imprisonment and/or fine and can result in cancellation of consumer card. 1. Full Name of the applicant (in block letters) ............................ 2. Father's/Husband's Name ..................................... 3. Complete residential address on which card is required......................... House No. ......... Galli/Mohalla/Street..........Locality............. 4. Full address of the persons for which consumer's card is required ...................... Sl. No Name in block letters Nationality Age Father's/Husband's Name Relation with applicant Date of arrival and period of stay in Delhi Circle No. from which shifted Place and State from which migrated (if any) Particulars of surrendered card/deletion certificate S.No. $ date issued by Identity Card No. For duplicate card in lieu of a lost/defaced/damaged card furnish following information also. Name of the card Holder Consumer F.P.S. No. Regn. No. Units Wheat eater/ Gas/Kerosene oil Ration drawn up to (H.O.F) card No. Cereal Sugar Rice eater user Note :- Strike out whichever is not applicable. DECLARATION I hereby solemnly declare that - 1. Information given in this form is correct. 2. Members including in column No. 4 above do(es) not draw specified food/articles from defence force or hold any Consumer card in his/their name or in any of the names mentioned above and their name(s) is/are not included in any other consumer card. 3. I am Gas/K. oil users. 1 2 Cylinders 4. I and other members included at Col. 4 are likely to stay in Delhi permanently. 5. Consumer card mentioned at Col. 5 above has actually been lost. 6. The members mentioned in col. 5 above are still residing at the given address and names are the same in the lost card. Signature of theApplicant COUNTERFOIL Registration No. .......... Date of receipt .............. Circle No. ............. Date of calling (if any) .......... Name of the applicant ......... In case of non-delivery of consumer card .. Signature of Counter Clerk ......... FOR OFFICE USE Issued Fresh/Permanent/Homeless Duplicate Card issued Signature of Card Writer Consumer Card No. F.P.S./ Regn. No. with whom attached Member Units Consumer Card No. FPS No. Regn. No. Units Signature of FSO/ Inspector HQ Date cereal sugar Adult minor cereal sugar F.P.S.NO........ Ration allowed from...... Regn.No........ Duplicate Receipt No...... Date............ For Rs.2.00 INSPECTOR'S PRE-VERIFICATION/POST-VERIFICATION REPORT Verified ............and contacted Shri.............HOF/other member/ neighbour, holder of consumer card No.....Regn.No.........With FPS No...... The particulars given in the application have been pre-verified/post-verified by me and are found to be correct. Recommended for issue of permanent/duplicate card in lieu of lost card/homeless consumer card for.....adults....minors. This card may be attached with FPS No....marked as Wheat/ Rice eater. This application is not verified on account of the following reasons/following discrepancies have been notified: 1. Date of receipt by the Inspector for verification....... 2. Date of verification by the Inspector............ 3. Date of return after verification by the Inspector....... 4. Date of receipt by the counter clerk............. Signature of Inspector with date Full Name:......... Signature of counter clerk Order of FSO Consumer Card No.....Received Signature/T.I. of card holder AUTHORITY I hereby authorise to Shri/Smt............who is an adult member of my family to receive the consumer card on my behalf. Signature/T.I. of applicant/H.O.F./Card Holder
