Government of West Bengal

Coloured
! Passport Size
LAKSHMIR BHANDAR SCHEME Photograph
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APPLICATION FORM - - 8" # -
9 :8
((∗Marked fields are mandatory)
(Please tick (√ ) appropriate boxes, wherever applicable)
(* . / & 0$ % -1 2 3 $)
( , % $ 5 6 (√ ) ))
Application ID (for officials only)
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APPLICATION FOR
FORM for LAKSHMIR BHANDAR SCHEME
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PERSONAL DETAILS &'( )

Duare Sarkar Registration no. *

.*
Above number will be obtained from Duare Sarkar Camp. The application will be received only
when this number is written. No other form will be accepted.

* + ।, (
- ।. / 0 - ।

Swasthyasathi Card no. *

!" .*
Aadhaar No. *
*

First Name # # Middle Name # # Last Name - $

Applicant’s Name *
$ #*

Mobile Number*
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Email Id., if available

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Date of Birth *
/ /
( *
Age as on 01/01/2021
Years $7
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First Name # # Middle Name # # Last Name - $

Father’s Name *
- # *
Mother’s Name *
# #*
Spouse Name
# #

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Caste* SC -: Others
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SC/ST certificate no. (Mandatory
Mandatory for SC/ST *)
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CONTACT DETAILS +' +'

State* W E S T B E N G A L
*
District*
&*
Police Station*
*
Block/Municipality/Corp.*
? / #< - &6/ -" *
GP/Ward No.*
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Village/Town/City*
@ #/ 3 *
House / Premise No.
B /$ C
Post Office*
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Pin Code*
- !*

BANK ACCOUNT DETAILS 1. 2 3 )

Bank Name*
$ D # *
Bank Branch Name*
$ D # *
Bank Account No.*
$ D 0 <E *
IFS Code*
%.F:.F !*

ENCLOSURE LIST (SELF ATTESTED COPIES) (Please tick (√ ) appropriate boxes)

+& * ( (5$( () / 7 ( 8 9 (√ ) )

1 Coloured Passport size Photograph∗

Photograph
*. - - 8" # - 9 :8 ∗
2 Copy of Swasthyasathi Card*
,. !"-F : 8 - *
3 Copy of Aadhaar Card *
G. !"-F : 8 - *
4 Copy of SC/ST Certificate, if SC/ST *
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5 Copy of Bank Pass Book* (First page of pass book/ cancelled cheque)
I. $ D - $% : 8 - (- $% # - / M )
6 Others (Please
Please specify)
specify
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2
 SELF DECLARATION 5 : ;)

(1) That I am a resident of West Bengal.

(*) # - N#$ O $ P ।
(2) That I do not earn any monthly remuneration/pension from any regular Government job
(,) # A 2 # R A # /- -% ।
(3) That all the information and documents submitted by me are correct to the best of my knowledge.
In case any of the information/ document is found to be false, penal action shall be taken against
me and the benefit will be terminated.
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Date: (Signature of Applicant)

: ( $ W )

…………………………………………………………………………………………………………………………………………………….

ACKNOWLEDGEMENT 5 < (
To be perforated and handed over to applicant 0= 6 8 $ 3$

I, ………………….., daughter/wife of……………………………………….., have submitted Lakshmir Bhandar

application on ……………………(Date).

#, ………………….............................., …………………………………………..….., -F /Z &[ \]

X $ -> …………........... # & #।

My mobile no. ………………………………

# # $ %& . ………………………………

Swasthyasathi Card no. ……………………………………………………….

!" . ……………………………………………………….

Aadhaar no. ………………………………………………………..

………………………………………………………..

……………………………………………………..
Signature of Receiving Official with seal
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Received on …………………… (date)

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