2/11/2020

Form Number: EIG521314143 District: 10 - SOUTH 24

State: S25 - West Bengal AC: 142-Magrahat Paschim
Form 6 - Fresh Inclusion PARGANAS
Form Type: Offline Part: 54 - Masidhat F.P. School
Section No.: 1 - Uttar Chak Raypur

KAMAL MALLIK / কামাল

Name : Gender : Male
মি ক
Rln MADAR MALLIK / মাদার
RLN Type : Father
Name : মি ক
DOB : 28/02/2000 Age : 19
Mobile
NA Email Id : NA
No. :
Street /
-- Village/ Town :-
Area :
Post
- Pin Code : 743609
Office :

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Checklist for BLO Designated Officer

Field Verification Address DOB/AGE Photo as per Specification [Y/N]
If age is greater than 21, has applicant given declaration [Y/N]
On field visit Applicant is found Absent Shifted Dead No Such Person
No of Application already applied
BLO Comments Applicant Details are Verified & Correct Data entry errors, if any
Name: _________________________________________ DOB/AGE:____________________
Corrections, if any
Gender:______
Rln Name: _____________________________________ RLN Type:_________
House No.: __________________ Street / Area:
_____________________________________________ Village/ Town: _________________
Post Office: ___________________________
District: ___________________ Pin Code: ____________________
Remarks: ______________________________________________________________________________________________

Date: ____________________
Place: ____________________ _________________ _________________
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