SPORTS DEVELOPMENT AUTHORITY OF TAMILNADU, CHENNAI – 600 003

APPLICATION FORM FOR “CHIEF MINISTER’S STATE SPORTS AWARD FOR THE
YEAR 2021-2022” FOR OUTSTANDING SPORTSPERSONS / COACHES /
PHYSICAL DIRECTORS / PHYSICAL EDUCATION TEACHERS

DISCIPLINE: ______________________

(Period: From 1st April to 31st March every financial year)

The application form duly filled in, should be forwarded through the Secretaries of
the concerned State Association/ The General Secretary, Tamil Nadu Olympic Association
in the case where the State Association is not functioning or under dispute to the Member
Secretary, Sports Development Authority of Tamil Nadu so as to reach by 10.06.2022.

To be attested by the
Association Secretary /
Authorized Signatory

1 Full Name of the applicant in BLOCK :

Letters
2 Date of Birth (In Christian Era) :
in Words and Figures
3 Place of Birth, District and State :
(Enclose Xerox copy of Nativity
certificate)
4 Father’s Name :

5 Applicant’s Occupation and Office :

Address with Phone No.

6 Present Residential Address with :

Phone No. (In Block Letters)

7 Permanent Home Address with Phone :

No.(In Block Letters)

8 Monthly Income :

9 Nationality :
 10 Performance and Achievements :
during preceding three years

10.1 Performance International level :

a. Participation and performance in Sports activities during the first preceding year (period from
1st April 2018 to 31st March 2019) at International level as a member of National Team.

SI. No Name of the Competition Venue and date Position Secured /

Participation

Note: 1. Attested Xerox copies of Merit/participation Certificates or Federation letter need to be

enclosed
2. In case of Coaches / PD / PETs – Declaration obtain from the trainees may be duly signed by the
trainees and enclosed with the application form.

b. Participation and performance in Sports activities during the second preceding year of the award
year (period from 1st April 2019 to 31st March 2020) at International level as a member of National
Team.

SI. No Name of the Competition Venue and date Position Secured /

Participation

Note: 1. Attested Xerox copies of Merit/participation Certificates or Federation letter need to be

enclosed
2. In case of Coaches / PD / PETs – Declaration obtain from the trainees may be duly signed by the
trainees and enclosed with the application form.

c. Participation and performance in Sports activities during the third preceding year of the award
year (period from 1st April 2020 to 31st March 2021) at International level as a member of National
Team

SI. No Name of the Competition Venue and date Position Secured /

Participation

Note: 1. Attested Xerox copies of Merit/participation Certificates or Federation letter need to be

enclosed
2. In case of Coaches / PD / PETs – Declaration obtain from the trainees may be duly signed by the
trainees and enclosed with the application form.
a. Participation and performance in Sports activities during the first preceding year (period
from 1st April 2018 to 31st March 2019) at the National level as a member of a State Team

SI. Name of the Competition Venue and date Position Secured / Indicate whether
No Participation represented
Tamil Nadu /
Department

Note: 1. Attested Xerox copies of Merit/participation Certificates or Federation letter need to be

enclosed
2. In case of Coaches / PD / PETs – Declaration obtain from the trainees may be duly signed by the
trainees and enclosed with the application form.

b. Participation and performance in Sports activities during the second preceding year (period from 1 st
April 2019 to 31st March 2020) at the National Level as a Member of a State Team

SI. Name of the Competition Venue and date Position Secured / Indicate whether
No Participation represented
Tamil Nadu /
Department

Note: 1. Attested Xerox copies of Merit/participation Certificates or Federation letter need to be

enclosed
2. In case of Coaches / PD / PETs – Declaration obtain from the trainees may be duly signed by the
trainees and enclosed with the application form.

c. Participation and performance in Sports activities during the third preceding year (period from 1 st
April 2020 to 31st March 2021) at the National Level as a Member of a State Team

SI. Name of the Competition Venue and date Position Secured / Indicate whether
No Participation represented
Tamil Nadu /
Department

Note: 1. Attested Xerox copies of Merit/participation Certificates or Federation letter need to be

enclosed
2. In case of Coaches / PD / PETs – Declaration obtain from the trainees may be duly signed by the
trainees and enclosed with the application form.
 I hereby declare the particulars given by me in this application are correct to the
best of my knowledge and belief.

Place:

Date:
Signature of the Applicant

11. The facts stated in the application of Thiru/ Tmt/ Selvi ___________________ Son/
Daughter/Wife of Thiru/ Tmt ________________________ are correct to the best of my knowledge
and belief. Further certified that the details given about representation of Tamil Nadu /
Department are also correct and he / she has been a well disciplined / sportsman/ Woman and
his/ her application may kindly be considered for the “Chief Minister’s State Sports Award”.

Honorary Secretary of the

Place: State Association/
General Secretary of the
Date: Olympic Association/
Authorized Signatory