nstrurtions: All details to be filled in Block Letters

Not required to print on fetter head;

o be printed on plofn A4 paper size;

~ esident

adhaar Number:
For update only)
1°18 9 9 5 J V3 3 3J J
r ll Name: I;=P=:6:~o.~r4J:.l4---1J_.w-=-~a~h1-
,___ -
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_,_
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C!i~C'q-:
A_, -':=_---=------=------=------_-_-_-_-_----=-_-_ -----=-----_ -_-_-_- _-_- __J/
a~-f

L---1- - - - - - - - - - - - - - - - - - '

C/o:

ouse No./ Bldg./ Apt:

treet/ Road/ Lane:

ndmark:

Area/ Locality/ Sector:

r-1
::=~=~t:_r=_t::_o:_Y=_~=_J=_-==--==--==--==--==--==
- -==--==--==--==--==--==--==--==-/
r llage/ Town/ City:
I Rl)hihi I
rost Office:

r strict:

rate: I D llhi

I o O8 S:-
Signature of the Resident/
Thumb/ Finger Impression

lesignation: '~=f'-l~t=A=======::::;:===~===~~==~::;:::;:::;~~===~
r ffice Address: ::£r!~{)~\}~~=L======~~G~~£~=~::::s~u~µ'=·r=-1";::;;=='==t~=~=
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======:: : : :'.
/ I K~Wf--1,_
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1)~1-tL --(l (;\9&'

r ntactNumber: I & y L1 r:-s~
s J_C_ _ _ _ _I - - - - - - - - ,
I hereby certify above mentioned details of the resident Checklist for Certifier
nd I am a .... (Tick awropriate box below) g-i.io overwriting ~ e date is filled ~ 's signature ~ er's details
!dent's Photo is cross signed and cross stamped (poper to photo or photo to poper)
Gazetted Officer - Group A

,,,___ _
Village Panchayat Head or Mukhiya
Gazetted Officer - Group B
P/ MLA/ MLC/ Muncipal Councilor

Head of Recog nized Educational Institution

Superintendent/ Warden/ Matron/ Head of In stitution
~'-;/,"ci~i..DJ,l
,
[ of Recognized shelter homes/ Orphanages 7l10HA~t:,'if·
p EPFO Officer Signature~ e Certifier

~OTE: This format is applicable fo r POI documents at SI. Nos. 17, 20, 21, 22, 31 & 32; POA documents at SI. Nos. 23, 24, 37, 38, 44 & 4S; POR documents at SI. Nos. 13
\ " ooa •• "m,ou • "· "°' •• s, " , ,s , , ' " """ " ' " " ' ~a,,., ( '"'°'~"""' o,a,,-) ~,, <aoo•, '°''• as am,ooeo ••m om, <o om,