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Amnexure-A-l APPLICATION FORM FOR CERTIFICATE FOR AN APPLICANT WHOSE FATEH! ‘The Naib Tehsitdar/Tehsitdar Sub:- CERTIFICATE FOR AN APPLICANT Wituoe vst ieccnas E Name of applicant (IN BLOGK LETTERS) eon Date of Birth (enclose proof 1 A— \o Row, | Rae of applicant atthe + Applicant is firetor second child ig is Present Address, Village ie WP.6 Diba WpanCe)| é Post Office VO Dohaldh 7 | Poles Staiaa Si a = Beni = District , s = Su ASTAR Taste (n€N Ek gap foe BOA ral SNR 5 Gen

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