Sl. No........ 'FORM-F' [See clause 10(1)] FOOD, CIVIL SUPPLIES & CONSUMER AFFAIRS DEPARTMENT GOVERNMENT OF HIMACHAL PRADESH Application for Consumer Card : 1. City/Town/Village/Panchayat...................................... 2. Whether new or duplicate with reasons................................ 3. Name of house-owner.......................................... 4. Name of the House (with house No.) ................................. 5. Name of the applicant..............Father/Husband.................. 6. Full address with occupation & designation............................. 7. Date/reason of arrival of in the distribution area.......................... 8. Total monthly income of family from all sources.......................... (with allowances for employees of the Govt./Semi-Govt. Departments/Corporations, Boards etc.) 9. Gas connections : Yes/No. Consumer No..................... DBC: Yes/No 10. Particulars of family members for which consumer card is required:- Name of the applicant and other members of the family living with the applicant Relationship with the applicant Occupation Age Place and State from where came with date of departure 1 2 3 4 5 1 2 3 4 5 6 7 8 9 10 .......................................................... Receipt of the application form Serial No.........Name of the applicant.............................. This acknowledgment should be produced on ............at ................. when distribution card will be issued if the application is found in order. Date........... Signature of receipt 11. I do hereby solemnly affirm and state that : (a) the information given in this form is true ; (b) Name of the persons mentioned in para-10 are in receipt of the ration from Army, neither names of these persons are entered in any consumer card in India ; (c) None of the person mentioned in para-10 are in receipt of regular diet from any Hostel/ Boarding House neither their names are entered in the ration cards issued for the Boarding House/Hostel. Myself or my family members have a gas connection No.........Single/Double Cylinder. Signature/Thumb impression of the applicant alongwith date 12. The applicant is the head of family and I know him personally ; I hereby certify that the information given above is correct; Signature of the Certifying / attesting Officer alongwith designation with seal INSTRUCTIONS FOR FILLING IN THE APPLICATION (i) The application should be filled in neatly while applying for a new distribution card. (ii) The persons coming from other state / city / town / village, should attach cacellation / migration certificate issued by the previous card issuing authority. (iii) If the applicant is a Government servant, he should get the application certified by the Head of the office. If the person is not a Government servant, he should get his application attested by a Muncipal Comissioner or a Gazetted Officer in the town or any other class of persons specially or generally authorized by the Government. .......................................................... FOR OFFICE USE ONLY Enquiry report of the officer / official :- Enquiry was conducted on the address given by the applicant in para-10 today and the facts mentioned in the application form have been found to be correct. Adults Children Infants Total Members Signature of the Enquiry Officer with Seal (Inspector, Food, Civil Supplies & Consumer Affairs/Gram Panchayat Vikas Adhikari). Date................ Code No. of the Consumer Card............ Serial No.................... Dated......... Signature of card preparing Officer/Official.
