APPLICATION FORMAT FOR FINANCIAL ASSISTANCE 1. FULL NAME OF THE APPLICANT: (In block letters) 2. ADDRESS FOR CORRESPONDENCE: Telephone no (if any): 3. FATHER'S/GUARDIAN'S NAME: 4. DATE OF BIRTH:-DD MM YY AGE ______YEARS ______ Months _______Days______ (Enclose age proof certificate) 5. GENDER:- Male Female [Indicate by tick mark ( ) in the appropriate box] 6. MARITAL STATUS: 7. NATIONALITY: 8. PLACE OF BIRTH: 9. CATEGORY: General/ST/SC/OBC 10. APPLICANT'S PERMANENT ADDRESS 11. TYPE OF DISABILITY: Degree/Percentage: 12. WHETHER DISABILITY CERTIFICATE ISSUED BY THE STATE MEDICAL BOARD HAS BEEN OBTAINED: YES/NO If yes, Certificate No. 13. FAMILY INCOME: (Income certificate to be enclosed duly signed and attested by DC/SDO/SDC) 14. OCCUPATION: Whether Working in Govt./Pvt. Sector DECLARATION I hereby declare that all the statements mentioned above are true, correct, and complete to the best of my knowledge and belief. I understand the in the event of any information being found false or incorrect at any stage or not satisfying the eligibility criteria according to the requirements my application is liable to be cancelled. I undertake to abide by the terms and conditions given by the Department. Date: Place: Signature
