Application Form for Information under section 6 (1) of the Act [See Rule: 4 (I)] FORM-A To The Public Information Officer (Name of the office with address) 1.Full name of the applicant: 2.Name of the Father/ Husband: 3. Permanent address: 4. Particulars in respect of Identity of the applicant: 5. Particulars of information solicited: (b) The period to which the information relates: (a) Subject matter of Information: Information &Public Relation Department Government of Orissa ToFrom (c) Specific details of information required: (d) Whether information is to be sent by post or received in person: (The actual postal charges shall be included in providing information) 6. Address to which information will be sent & in which form: 7. Has the information been provided earlier? (e) In case by post ( ordinary, registered or speed): NoYes Published on National Portal of India (india.gov.in) 8. Is this information not made available by the Public authority? 9. Do you agree to pay the required fee? 10. Have you deposited application fee? (If yes, Please indicate details of such deposit) 11. Whether belongs to BPL category, have you furnished the proof of the same? NoYes Place : Date : Full Signature of the applicant Address Office of the Public Information Officer Received the application from address- on seeking information. Place: Full name of Public Information Officer Date: Designation & Seal Yes No No Yes Yes No Published on National Portal of India (india.gov.in)
