ULHASNAGAR MUNICIPAL CORPORATION CITIZEN FACILITATION CENTRE SUBJECT:- ROAD DIGGING PERMISSION Token Number (For Office Use) Date:- / / (If Citizen Identification Number is given, do not fill below Details) Applicant's Details: Last Name/ Surname Name Father/Husband's Name Details of Society (If Application from Society): Name Of Society: Designation Address: Head Information House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Ward Committee No.: 1 [ ] 2 [ ] 3 [ ] 4 [ ] Electrol Panel No.: Telephone No. (if any): Contact Person: Email Address (if any): Necessary Particulars about above service: Head Information 1 Name of Road to dig 2 Number of the Ward committee 1 [ ] 2 [ ] 3 [ ] 4 [ ] 3 Electrol Panel Number 4 Reason for digging of Road 5 Measurement of Road to dig (length & width) length mtr. width mtr. Necessary Enclosures related to above application are enclosed as under. (Please tick [ ? ] for YES or tick [?] for NO) Enclosures Yes/No 1 Location map for Road digging work [ ] Citizen Identification Number Declaration I/We................................................................................................. state on solemn affirmation that the above information is true and correct to the best of my/our knowledge. If the information given is found wrong then I/We shall be held legally liable for its consequences. Date:- Applicant's Signature ( ) The document may please be delivered to: 1. Self/Nominated Person [ ] a) C.F.C. [ ] b) Camp No. [ ] Name of Nominated Person (________________________________________________) 2. By Post a) U.P.C. [ ] b) Register A.D. [ ] 3. Courier [ ] (Not to be filled if address is same as above) Correspondence Address:- Last Name/ Surname Name Father/Husband Name House/Building/Soc. Name: Flat/Block/Barrack No.: Wing/Floor: Road/Street/Lane: Area/Locality/Town/City: Taluka: Pin code: Email Address (if any):
