GOVERNMENT OF GOA, DIRECTORATE OF ANIMAL HUSBANDRY& VETERINARY SERVICES, PASHUSAMVARDHAN BHAVAN,PATTO, PANAJI - GOA APPLICATION FORM FOR BACK-YARD POULTRY UNITS UNDER SPECIAL COMPONENT PLAN SCHEME 1) Full Name of the applicant: - -------------------------------------------. (in block letters) Surname First Name -Father's/Husbands Name 2) Permanent Address (a) House No. ............. (b) Village Ward............. (c) Taluka ............... (d) District .............. 3) Educational Qualification -------------------------------------------------- 4) Employed/Unemployed --------------------------------------------------- 5) Age ----------------------------------------- 6) Caste -------------------------------------- 7) Number breed of existing poultry birds with the applicant, if any -------------------------------------------------------------------. 8) Annexure to be attached a) Caste Certificate 9) I hereby certify that if information furnished by me in the application form is true to the best of my knowledge & belief & also agree that in case it is found false I shall be liable for any action as Government may find it fit and appropriate to impose upon me. Dated: - Signature of Applicant (Name) FOR OFFICE USE ONLY Recommendation from --------------------------------------------------- Area Veterinary Officer/Assistant Director ------------------------------ Dated: - Signature Designation OFFICE SEAL
