DIRECTORATE OF CIVIL DEFENCE : GOVT. OF N.C.T.

OF DELHI ft
District Magistrate (East) Office Complex, B- Block, L.M. Bund,J^-
Krishan Kunj, Shastri Nagar, Delhi -110031
Tel: 011-22422855, E-mail: delhiciviidefencehq@qmail.com

FORM "A"
Application Form : For Enrolment as Civil Defence Member

Applicant's Detail

1. . UID (AADHAR) No.

2.Name of Applicant in Full: ^___

Applicant color
3.Name of Father/Husband/Mother: _
Passport Size
4.Gender: Male | | Female Other Photograph
Size-5x4.5(Cm.|
5.Date of Birth Or
nn
2 x 1.75 (Inch)
6.Height Cms. 7. Blood Group:
8.Identification Mark:"
9.Nationality—•

10.Educational Qualification. ' '• - ' *-.

_ (Primary, education is essential)
t r. r-
11.Language Known , - J I' J' (Writing/Reading/Speaking)
12.Technical Qualification^ any) ,| ' - '-,

13.Occupation & Address of Employenwith "phone No..

_-(A certificate from employer to be submitted in attached format)

14.Previous Experience in Civil Defence (if any)
15.Previous Experience in Home Guards (if any)
16.Do you have any vehicle (if so, give'detail) • . 17. Do you know driving :.
18. Bank :I1' .
! Branch.
Account No.: . IFSC No. L MICR No.

, I i
19. Mobile No.: ,'e-MaillD:

20. Present Address :

House Name/No : , " Sub-Locality
Locality . ''-' - Village/Town,
State Distnct , " '
PIN Code ^, "Country '

Note : Residents of Delhi only can apply.

21.Whether the Present and Permanent Address is same' Yes. NO
22.If No, Permanent Address - -— _- - - -
House Name/No: .Sutj-Locality._
Locality:. ~'.i~\ ^— Village/Towni
.'~H 'IT..
State•2-J' "' District - J;
PIN Code: i—i—i—i—i—i—i Country
 DIRECTORATE OF CIVIL DEFENCE : GOVT. OF N.C.T. OF DELHI
District Magistrate (East) Office Complex, B- Block, L.M. Bund,
Krishan Kunj, Shastri Nagar, Delhi -110031
Tel: 011-22422855, E-mail: deihicivildefencehq@qmail.com

23. Identify Proof of Applicant (Please tick one, provide the document No. and attach the same )
|| AadharCard|| PAN Card
Ration Card with Photograph
| 1 Voter ID Card | | Passport Driving License
Document No:

24. Present Address Proof of Applicant (Please tick one, provide the document No. and attach the same )
I I AadharCard Voter ID Card | | Driving License .
| | Passport
| | Ration Card
I I Bank Passbook Document No:

25. Self Declaration: FORM-"B"

(i) I have read the "Civil Defence Act and Civil Defence Regulations 1968"
(ii) As far as I know, I am Physically fit to render efficient service as member of the Corps.
(iii) If my application is accepted, I am prepared to service as a whole-time/part-time member of the Corps, i.e. to
undergo the appropriate training and, in the event of an emergency occurring whilst I remain a member of the
Corps to carry out my obligation as a member thereof. There is no pending case against me in any court.
(iv) I swear/solemnly affirm that I will be faithful and bear true allegiance to India and to the Constitution of India as by
law established, and that I will loyally carry out duties entrusted to me.
(v) I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and
nothing has been concealed therein. 1 know that I am liable for penal/ criminal action for giving wrong/incorrect
information. .,„ .,,J

Date: [pp [^ 20

Applicant's Signature: ;
Place:

y\
W

,, jr .V* ,-

*Ii
 DIRECTORATE OF CIVIL DEFENCE : GOVT. OF N.C.T. OF DELHI
District Magistrate (East) Office Complex, B- Block, L.M. Bund,
Krishan Kunj, Shastri Nagar, Delhi -110031
Tel: 011-22422855, E-mail: delhicivildefencehq@qmail.com

FOftM "C"
Membership Certificate

Civil Defence Corps

Applicant's Detail

1.Enrolment No.: _ District: Division :

2.Name of Applicant in Full :. Applicant color
Passport Size
3.Name of Father/Husband/Mother : Photograph
Size-5x4.5 (Cm.)
4.Gender: Male | | Female | | Other | |
Or
5.Date of Birth: 2x1.75 (Inch)
on mm yyyy
6.Identification Mark
7.Nationality:.

8. Mobile No.: Email ID: ' , .

9. Present Address
House Name/No: 1 " Sub-Locality
Locality: Village/Town •
State' : ". " District''^- * '
PIN Code . : r~~ ..; Country I - '

10.Name of Civil Defence Corpsjin which deployed'-:'

11.Assignments :;,' \ t'

12. Name & Address of Next of Kin •

Date: QD mm 20YY Vs I I i.'i

-Applicant's Signature,:
and thumb impression'
Place: {Lefthand.(Men)/ :
Right hand (Women)}

Date of issue Office Stamp of Issuing-Authority, Signature & Sealiof Zonal Controller
 DIRECTORATE OF CIVIL DEFENCE : GOVT. OF N.C.T. OF DELHI
District Magistrate (East) Office Complex, B- Block, L.M. Bund,
Krishan Kunj, Shastri Nagar, Delhi -110031
Tel: 011-22422855, E-mail: delhicivildefencehq@gmail.com

Verification of Character & Antecedents for New Enrolment/ Renewal/

Promotion in Civil Defence Corps as Volunteers/ Wardens

1. UID (AADHAAR) No.

2.Name of Applicant in Full : Applicant color

Passport Size
3.Name of Father/Husband/Mother :.
Photograph
4.Gender : Male | | Size-5x4.5 (Cm.)
Female | | Other | - |
Or
5.Date of Birth (Attach self attested copy) 2 x 1.75 (Inch)
nn MM Yyyy
6.Identification Mark :
7.Height (in cm): _ Chest (in cm)_
8.Weight (in Kg) • : Candidate's Signature

9. Mobile No.: ,e-Mail ID

10. Present Address with proof (attach self attested copy)
House Name/No : 1 ' -=• .x Sub-Locality •;;_!_
Locality: ' : . "i Village/Town"'_i_
State '
•District,",, |'
PIN Code • • CountryJ, :'
11 11 - !

11.Any Photo ID No.: (Attach self attested copy)

12.Educational Qualification
13.Police Station : . Beat/Post No." •.
14.Enrolment No.: _ Review Date . <j_ -_Rank
I— L'

Has applied for enrolment him /her self in Civil Defence Corps as,a volunteer/ Warden, since the residence of the
member falls in your police station jurisdiction You are requested to verify his/ her character from your police record
and send this letter with your remarks to the undersigned.'t,
Therefore, requested to send the report back to this office'atlthe earliest but not latter then 15' (Fifteen) days,
otherwise it will be presumed that there is nothing out standing in the record'of Police Station against the above said
applicant and He/ She will be enrolled by the Deputy Controller/SDM in public interest' ^
NOTE: Police verification fees for Civil Defence Wardens/-Volunteers, is waived off as per order of (Joint
Commissioner of Police (NDR) No.3381-98/ SO (AC-1) NDR dated. 06.10.2008.

To be filled up by the Police Authorities

Checked by: •: " - Enrol. No"/ Rank.

Office Telephone No. Signature:

MHC (R) PS _

Sub-Divisional Magistrate/Dy. Controller (Civil Defence)

Sub-Division;
SHO
 DIRECTORATE OF CIVIL DEFENCE : GOVT. OF N.C.T. OF DELHI
District Magistrate (East) Office Complex, B- Block, L.M. Bund,
Krishan Kunj, Shastri Nagar, Delhi -110031
Tel: 011-22422855, E-mail: delhicivildefencehq@qmail.com

CERTIFICATE FROM EMPLOYER

(To be signed by Head of office or Manager level officer on the letter head of the organisation)

It is certified that Sh./Ms.

r/o
is an employee of this organization and this office has NO OBJECTION if he/she joins Civil Defence Corps.
This office shall release him/her for attending training and for duty in an emergency at any time and for any
period and in any part

Date: Authorised Signatory

with Name & Seal
(To be typed on the letter head of the organisation having address and phone numbers)

Note :- It is clarified by the Directorate of Civil Defence that normally the training is scheduled to be held during
holidays/ Sundays/out of office timings and the emergencies are not likely to arise very often.