APPLICATION FORM FOR ISSUANCE OF SENIOR CITIZEN

IDENTITY CARD/ RENEWAL OF IDENTITY CARD.

Photo

Photo

1.

Name

.....................................................

2.

Fathers/Husbands Name

.....................................................

3.

Date of birth/Age

.....................................................

4.

Whether domicile of Haryana

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5.

Permanent Address

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6.

Whether belongs SC/ST/BC

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Ex-serviceman
7.

Whether belongs to minority

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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
Date :

Signature of the Applicant

Enclose :- following documents

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

Contact No. .........................