m§Ñfhu¢ rh‹W é©z¥g« /Authorization form application

FL«g¤ jiytç‹ bga® k‰W« FL«g m£il v© / Family

Head Name and Family card Number (UFC number)

1.

2.

FL«g m£il cW¥Ãd®fë‹ bga® / Family members in the 3.

ration cards
4.

5.

m¤ÂahtÁa¥ bghU£fis bgw Koahjj‰fhd fhuz« /

Reasons for unable to get commodities

FL«g m£iljhuç‹ gÂÎ brŒa¥g£l if¥ngÁ v© /

Registered Mobile Number of the Ration Card Holder

m¤ÂahtÁa¥ bghUŸ bgw ãaä¡f¥gL« egç‹ bga® k‰W«

FL«g m£il v© / Name of the person authorized to lift
commodities and Family card number (UFC)

rh‹W / Certificate
nk‰f©l fhuz¤Âdhš vdJ FL«g m£il¡F cça m¤ÂahtÁa¥ bghU£fis bgw eh‹ nk‰F¿¥Ã£l
ÂU/ÂUkÂ__________________________________ j/f/bga® _________________________ v‹gtiu
ãaä¡»nw‹. Ïš VnjD« KiwnfL ãfœªjjhf f©l¿a¥g£lhš vdJ FL«g m£il m¤ÂahtÁa¥ bghUŸ bgw
Koahjgo Kl¡f« brŒa¥gL« v‹gij m¿nt‹. nkY«, vdJ FL«g m£il¡F v‹Dila gÂÎ brŒa¥g£l miy¥ngÁ
v©â‰F tU« xU Kiw fl΢ brhš _y« m¤ÂahtÁa¥ bghUŸ tH§f¥gL« v‹gij m¿nt‹. I hereby authorize above
mentioned person Mr/Ms.____________________________________________ S/W/o_____________________________ to draw the
entitled commodities from the FPS. I know that, my family card will be suspended if I misuse my family card for getting commodities.
Further, I understand that the commodities will be issued to my ration card based on the One Time Password received in my registered
mobile number.

é©z¥gjhu® ifbah¥g«
Signature of family card holder

t£l tH§fš mYtyç‹ rh‹W

ehŸ: t£l tH§fš mYtyç‹ ifbah¥g«