SPORTS DEVELOPMENT AUTHORITY OF TAMIL NADU, CHENNAI -84 APPLICATION FORM FOR 'CHIEF MINISTER'S STATE SPORTS AWARD' DISCIPLINE:________________________ This application form is for "Chief Minister's State Sports Award for the year 2006-2007. The application form duly filled in, should be forwarded through the Secretaries of concerned State Association / The General Secretary, Tamil Nadu Olympic Association in the case where the State Association is not functioning or under dispute, to the Member Secretary, Sports Development Authority of Tamil Nadu so as to reach him by 30.12.2006. PHOTO To be attested by the Association Secretary 1. Full Name of the applicant in BLOCK letter 2. Date of Birth (In Christian Era) in Words and Figures 3. Place of Birth, District and State (He / She to enclose xerox copy of Nativity certificate) 4. Father's Name 5. Applicant's Occupation and Office Address /school address 6. Present Residential Address (In Block Letters) : Thiru / Tmt/ Selvi : : : : : 7. Permanent Home Address (In Block Letters) 8. Monthly Income : 9. Nationality : 10. Performance and Achievements. : 10.1 Performance International Level a. Participation and performance in Sports activities during the first preceding year 01.04.2003 to 31.03.2004 at International level as a member of National Team. Sl. Name of the Competition. Venue and date Position Secured / No. Participation NOTE: Attested Xerox copies of Merit / participation Certificates or Federation letter need to be enclosed. b. Participation and performance in Sports activities during the second preceding year of the award year (period from 01.04.2004 to 31.03.2005) at International level as a member of National Team. Sl. Name of the Competition. Venue and date Position Secured / No. Participation NOTE: Attach the attested copies of Merit Certificates. c. Participation and performance in Sports activities during the third preceding year of the award year (period from 01.04.05 to 31.03.2006) at International level as a member of National Team. Sl. Name of the Competition. Venue and date Position Secured / No. Participation 10.2 Performance at National Level Competitions. a. Participation and performance in Sports activities during the first preceding year 1.4.2001 to 31.3.2002 at the National Level as Member of a State Team. Sl. Name of the Venue / Date Position No. Competition secured / Participation Indicate whether represented Tamil Nadu / Department NOTE: Please attach the attested copies of Merit Certificate. b. Participation and performance in Sports activities during the second preceding year of the award year 1.4.2000 to 31.3.2001 at the National Level as Member of a State Team. Sl. Name of the Venue / Date Position Indicate whether No. Competition secured / represented Participation Tamil Nadu / Department NOTE: Please attach the attested copies of Merit Certificate. c. Participation and performance in Sports activities during the third preceding year of the award year 1.4.99 to 31.3.2000 at the National Level as Member of a State Team. Sl. Name of the Venue / Date Position Indicate whether No. Competition secured / represented Participation Tamil Nadu / Department NOTE: Please attach the attested copies of Merit Certificate. I hereby declare the particulars given by me in this application are correct to the best of my knowledge and belief. Place: Date : Signature of the Applicant 11. The facts stated in the application of Thiru / Tmt. / Selvi __________________ Son / Daughter / Wife of Thiru / Tmt.__________________________ are correct to the best of my knowledge and belief. Further, certified that the details given about representation Tamil Nadu / Department are also correct and he / she has been a well disciplined sportsmen / women and his / her application may kindly be considered for the "Chief Minister's State Sports Award". Place: Honorary Secretary of the State Association / Date : General Secretary of the Olympic Association.
