Instructions: All details to be filled in Block Letters

To be printed on plain A4 paper size Not required to print on letter head

✔ Resident Non-Resident Indian (NRI) ✔ New Enrolment Update Request

Aadhaar Number:

Full Name: khushbu kumari

Date of Birth: 24-06-2003

Gender: FEMALE

Mobile No: +91-8076889124

Email Id:

C/o: sushil kumar

House No./ Bldg./ Apt:

Street/ Road/ Lane: punch kutir

Landmark: ball factory

Area/ Locality/ Sector: near realiance petrol pump Resident’s Recent Colour

Village/ Town/ City: Chipyana Buzurg Photograph 3.5cm x 4.5 cm

Post Office: Chhipyana Cross Signed and Cross

District: Gautam Buddha Nagar Stamped by the Certifier.

State: Uttar Pradesh NB: DO NOT OVERLAP

Signature of the Resident/
PIN Code: 201009 Thumb/ Finger Impression WITH TEXT BOXES

Name of the Certifier:

Designation:

Address:

Contact Number:

I hereby certify above mentioned details of the resident(Tick appropriate box below)
Gazetted Officer - Group A

Village Panchayat Head or Mukhiya

Gazetted Officer - Group B Stamp of the Certifier

MP/ MLA/ MLC/ Muncipal Councilor

Tehsildar

Head of Recognized Educational Institution

Superintendent/ Warden/ Matron/ Head of Institution of Signature of the Certifier

Recognized shelter homes/ Orphanages