APPLICATION FOR NEW FOOD SECURITY CARD

Head of the Household Details:

Card Type*: FSC ( )

UID (Aadhaar)*: _________________ Name of Head of the Family*: _______________________
HOF Father / Spouse Name*: __________________ Gender*: Male ( ) Female ( ) Transgender ( )
Age*: ______ Religion*: _____________Social Status*: General ( ) BC ( ) SC ( ) ST ( ) OTHERS ( )

Gas Connection Details:

If Gas Connection is available: YES ( ) NO ( ) if YES

Gas Connection Status*: Deepam ( ) Double ( ) No Cylinder ( ) Single ( )
Gas Company Name*: BPCL ( ) HPCL ( ) IBP ( ) IOCL ( ) NA ( )
Gas Agency Name *:___________________________ Consumer No*: ________________

Residence Address:

Door Number*: __________ Locality/Landmark*: _______________District*: _________________

Mandal*: ________________ Village/Ward*: __________________ Pin Code*: ________________
FP Shop No*: _____________________________ SKS Form No: _____________________________

Add Member Details (Including HOF) *

RELATION
AADHAAR NO. EID MEMBER NAME SRDH AGE GENDER HOF(Y/N)
WITH HEAD

Informant Details:

Informant Name*: _________________ Informant Relation *: __________Mobile No*: _______________

Aadhaar Proof Document*: __________________ Address Proof Document*: _______________________
Delivery Type*: Manual ( ) Local post ( ) Non Local post ( )

Encl Documents List:

1. Application Form*
2. Aadhaar Proof Document*
3. Address Proof Document*
Applicant’s Signature