/nstrzjcb'ons..

All details to be filled in BIo€k Letters ITo be valid for 3 months from date Of issue)

Ilo be printed ori plain A4 paper size; Not reciuired to pr.Int on letter head; 2_ 0 2_

EResident I Non-Residentlndian(NRl) I NewEnrolment E] UpdateRequest

Aadhaar Number:
(For update only)
2 C) 2 6 2:42_ 06L8
Full Name: S 1] R A D DHA

C/a: SUBrD ALE

HouseNo./Bld+a/Apt:
.ifeJ ` y

Street/ Road/ Lane:

Landmark:

Area/ Locality/ Sector:

Village/ Town/ City:

c,tj__ErefeA_I L_ DAi
pest office:
a FI E NGL
Dist,ict:

State:

arLrm"5evi
PIIt Cede:
I I I .3 a 8
Signature o`the Resider:I/ ' \'+`+:
Date of Bilth: 2- 0 a `7 Thumb/ Finger Impression -

Name of the Certifier:

Designation:

Cffife Address:
H 0 L' F? f\ ti

Coritact Number: 8 3o 2-,3 I 3 2{

I herch`/ certif`/ above mentioned details of the resident Checklist for Certifier
and I am a"., (Tick appropriate box below)

II Gazetted Officer -Groilp A

E<o overwriting Ertssue date is fiHed Er6lesident's signature
ErResident's Photo is crciss signed and cross stamped /paper fo pfroto or pflofo to pap€rJ
Erfem.fier's details

I
Village Panchayat Head or Mukhiya

Gazetted Officer -Groilp a

II
Etryp/hath/MLc/Muncipaicounciior
Tehsildar

Head of ftecQgnized Educational Institution

iT-,,
OutQ3oh4o7.2L
r' / .-i;` , -

`c,' 1~` I
I Superintendent/ Warden/ Matron/ Head of Institution n\". r.` rh\ i{~`E,l.f:3 :\v=,C-,':rLL-Ll ` Lr

I Of Recognized shelter homes/ Orphanages

EPFO Officer
Signature a Stamp Of the CErti-fier