do& 5, 370 B6: 9848158854

esogadsggvaso

*******
********.
. . .

*********
****
****.

. ssoáesn6.
/rám6.
So o ao66 isdosb . r.

s ad....
*******.

. dbeddtin,

Don

2. * * * * * * * * * . a **

3.

*******
* ******

5.

(ed árgáno D56áwen 3Ochsysn)

.

1. s 5 S 5
2. s5 5/sgr5 s/atbto KsQo F Kse» #
1. joE S 30. *** **************

2. Z s 5 3o. **a*s4*******

3. baws a.d. *****************

 AND

Check Slip for Enquiry Officer Certificate Type

Transaction Number:

Name of the Applicant

S/o, Dlo, Mo,Flo, W/o, H/o, Clo

Address
1 VRO
Caste/ Income

Conduct of enquiry at door level

Recommendation of the VRO

|Signature of the VRO

Verification of report of the VRO

Verification of records produced
2 MRI by the applicant

Recommendation of the MRI

Signature of the MRI

Remarks
MRO

Signature of the Tahaslidar