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