(See Bye law -6) Application for Grant of Financial Assistance to Media Person 1. Full name of Media Person . 2. Father's name . 3. Mother's name . 4. Name of spouse . 5. Name of the Journal . (specify the periodicity) 6. Length of service in the field . (Certificate issued by the journal authority to be attached in original) 7. Date and place of birth . 8. Address:-Present . Permanent . 9. Period of residence in the . present address DECLARATION I, .................... hereby solemnly affirm and declare that the particulars furnished above are true and I have not suppressed any material fact that will disentitle me for the grant of financial assistance. Place Date Signature of the applicant [See bye-law 6(a)] CERTIFICATE Of NATIONALITY AND NATIVITY This is to certify that Thiru ............... is a citizen of India. 2. He is a native of Puducherry by virtue of birth / continuous residence for not less than five years and he is residing at present continuously from ........ to .......... Place : Signature Date : Name in Block Letters Designation Seal [See bye-law 6(b)] SERVICE CERTIFICATE Certified that Thiru................... son of Thiru................... has been serving continuously for more than 10 years as Media Person in the Newspaper/Magazine Viz......... registered with the Registrar of Newspapers, Government of India, New Delhi. Place Signature Date Name in block letters Seal Designation [See bye-law 6 (c)] VERIFICATION CERTIFICATE Certified that application of Thiru.................... son of Thiru........................ for financial assistance from the Chief Minister's Welfare Fund has been scrutinised and the particulars furnished by him therein are found to be correct Place Signature Date Name in block letters Designation FORM-V [See bye-law 9] RECEIPT Puducherry, Dated Received with thanks a sum of Rs. .......... (Rupees .....................................) vide Cheque No............ dated ........... from the Hon'ble Chief Minister, Pondicherry towards the grant of financial assistance from Chief Minister's Welfare Fund. Identified by Signature : Director of Information and Publicity Name and Address :
