Government of Tamil Nadu

Civil Supplies and Consumer Protection Department

APPLICATION FOR NE FA!IL" CARD
ZONE / TALUK APPLICATION NO (computer generated)
Si#nature $or%
T&um' Impression of
Applicant
Note: Application !ould
"e #illed up in "lac$ in$
() Applicant*s Name
Name (Engli!)
+) Fat&er*s , -us'and*s Name
Name (Engli!)
.) Full Adress
Telep!one: %o"ile: Email :
/) Details of famil0 mem'ers $1rite &ead of famil0 first%2
&l'
No
Name
(ate o#
"irt!
&e)
Nation *
alit+
,elation
!ip
Pro#e
ion
%ont!l+
Income
(In ,')
Election P!oto
Identit+ Card
Num"er
(I# a"o-e ./ +ear)
.'
0'
1'
2'
3'
4'
5'
/'
6'
.7
3) Enclosed documents) Please tic4 $ %
. 8Surrender Certificate9 along :it! rele-ant #amil+ card iued "+ t!e card iuing
aut!orit+ i# an+ card i iued in t!e pre-iou addre (or)
0 8Name Deletion Certificate9 #rom t!e parent or guardian #amil+ card or 8Non*incluion
o# name Certi#icate9 iued "+ t!e card iuing aut!orit+ in t!e pre-iou addre (or)
1' 8No card certificate9 iued "+ t!e card iuing aut!orit+; i# t!ere i no #amil+ card in
t!e pre-iou addre
Applicant are ad-ied to collect an ac$no:ledgement lip :it! erial num"er a#ter u"miion o# application in t!e talu$ or Zonal o##ice'
,ation card application !a-e to "e decided upon "+ T&O or AC concerned :it!in 47 da+ o# application :it! necear+ document a a"o-e
Passport si5e P&oto
of
-ead of Famil0
3 cm ) 1'3 cm
6) Proof of residence: <o: long doe t!e applicant li-e in t!e preent addre= Encloe cop+ o# an+
one document "elo: a proo# o# reidence ( Applicant> name ? addre mut appear in t!e document)
Please tic4 $ %
Document ID No)
. @oter Identit+ Card
0 Propert+ Ta) in cae o# o:n !oue
1 Electricit+ Aill
2 Telep!one Aill
3 Bront Page o# Aan$ Pa Aoo$
4 Allotment order in repect o# peron reiding at
!oue allotted "+ &lum Clearance Aoard
7) Details of Gas connection
(a) C!et!er t!ere i ga connection =' Pleae tic$ ( ) : De / No
(") I# +e; #ill up t!e #ollo:ing detail:
(etail Connection I Connection II
a) Name o# peron in :!oe name connection i regitered
") Oil Compan+ (APC / IOC / <PC)
c) LPE Conumer Num"er
d) Name o# t!e Ea Agenc+
e) Num"er o# C+linder ( ) Pleae tic$
. 0 . 0
8) Option 2 Please tic4 $ % 2
,ice and Ot!er Commoditie
Additional &ugar in lieu o# rice
(on>t :ant an+ commodit+
Police Card
Boret Card
9) Certificate: T!e a"o-e particular are true to m+ $no:ledge' I# it come to notice at a later date t!at
particular gi-en "+ me are eit!er :rong or contrar+ to trut!; I am a:are t!at t!e #amil+ card iued to
me :ill "e cancelled and action purued againt me under Eential Commoditie Act (Act .7 o# Central
Act); .633'
Place
(ate &ignature o# <ead o# Bamil+
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** * * * * ** * * * * * * * * * * *
mYtyf gzpf;F kl;Lk; $for Office :se onl0%
District Code District -ead ;uarter< De No
Talu4 Code LPG : Oil Comp+
Local =od0 Name
Place Code C+linder
Area Code (ealer
Local =od0 Grade2
@P / TP / %cplt+ / Corporation
ard Code Card Option
S&op Code Income $mont&l0%
jzpf;if Ma;thsh; bgah; :
Street Code Cate#or0 Ci-il Boret Police AAD
Pin Code Old Famil0 card No2
cjtp Mizah; / tl;l tGA;fy;
mYtyh; bgah; :
jzpf;if Ma;thsh; Ma;t[ Fwpg;g[ :
ifbahg;gk;
cjtp Mizah; / tl;l tHA;fy; mYtyh; Miz:
ifbahg;gk;
Ce :elcome +ou to record +our #eed"ac$ a"out er-ice pro-ided "+ T&O /AC o#ice concerned at our :e"ite :
:::'conumer'tn'go-'in