APPLICATION FOR FAMILY IDENTITY CARD

ANDAMAN AND NICOBAR ISLANDS

Serial No. of the Register

1. Full Name (In block letters) ……………………………………………………………….

2. Father’s / Husband's Name……………………………………………………………….

3. Name of Head of Family ……………………… Identity Card No……………………..

4. Sex………………………Age………………………Adults……………………………….

Child…………………………………

5. House Address ……………………………………………………………….

6. Occupation …………………….. Annual Income…………………………

8. Persons for whom Family Identity Cards are required :-

Name Age Relationship with Occupation Remarks

(BLOCK LETTERS) Head of Family

1.

2.

3.

4.

5.

6.

7.
8. Existing Card No…………..FPS.No…………………..

9.I Solemnly declare that to the best of my knowledge the above information is correct.

Signature of thumb impression of Applicant

Date:

1. Signature of Enumerator.

2. Signature of Panchayat Pradhan/Municipal Councillor/Village Captain

3. Report of Enquiry Inspector/Assistant Director(Civil Supplies)

4. Cards prepared and checked on.

Received Family Identity Cards/Nos.

Date…………….19………

Signature of thumb impression of Applicant

……………………………………………………………………………………………………………

Counterfoil

Name of applicant……………………………….S/o,W/o,D/o…………………………………………

Address………………………………………………………………….

Date………………19………………….

Signature of Enumerator.