APPLICATION FORM FOR ISSUANCE OF SENIOR CITIZEN

IDENTITY CARD/ RENEWAL OF IDENTITY CARD.

1. Name .....................................................

2. Father’s/Husband’s Name .....................................................

3. Date of birth/Age .....................................................

4. Whether domicile of Haryana .....................................................

5. Permanent Address .....................................................

6. Whether belongs SC/ST/BC .....................................................

Ex-serviceman

7. Whether belongs to minority .....................................................

8. Whether your name appear in .....................................................

the BPL list of so then indicate

BPL No.

9. Whether getting Old Age .....................................................

Allowance/Handicapped Pension

Government ?

10. In case of renewal, furnish following information :-

a) Identity Card No. .....................................................

b) Date of issuance of I/card .....................................................

c) Date of expiry of the I/card .....................................................

d) Name of Issuing authority .....................................................

Place : HISAR Signature of the Applicant Date : Enclose :- following documents Contact No. .........................

1. copy of ration card Attested 2. Two Photo 3. Age proof Certificate Attested 4. copy of Voter Card Attested

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