cERTIFICATE FOR AADHAAR ENROLMENT/ UPDATE(TO BE USED ONLY AS PROOF OF ADDRESS.

)
lnstructions:All details to be filled in Block Letters (To be valid for 3 months from date of lssue,)

To be pinted on plain A4 paper size; Nat required to be ptinted on letter head;

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4/ L) <,/ 4

Aadhaar Number:
V Resident [-l uon-nesiOentlndian(NRl] n NewEnrolment M Upo"t"Request

(For update only) 2 0 2 1 0 4 8 I 6 0 5 4

Full Name:
N A J I N A M U D I

C/o:
S A H A D E V K o R A tvl U D I

HouseiloJ Bldg,lApt;

StreeU Roadl Lane:

LandMark;

Area/ Localityl Sector:

T o L A B H A N G I

Village/ Town/ City:

S A I Y A D P U R
Post Office:
H A R K H o R K H A
Distric-t:
M A L D A
State;
W E S T B E N L, A L
+-

PIN Code:
7 3 2 1 2 4
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t

Signature of the Residenu

Date of Birth:
0 2 0 1 2 0 0 3 Thumb/ Finger lmpression

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Certifier's Details (To be filled by the certifier Only)

Name of the Certifier:
R E N U K A K H A T U N
Designation:
P R o D H A N B A I R G A C H I I I G P
Office Address:
B A I R G A C H I ( 2 ) G A Z o L E

M A L D A W B 7 3 2 1 0 2
Contact Number:
7 0 6 3 4 7 7 4 2 I
I hereby certify above mentioned details of the resident Checklist for Certifier
and I am a.... (Tick appropriate box below)
EI *o overuriling M ,""r" date is filled 17 Resident's signature M Certifier's details

[-l CazetteO Officer - Group A I nesiOent's Photo is cross signed and cross stamped (Paper to photo or photo to paper)

M Vittrg" Panchayat Head or Mukhiya

GazetteO Officer - Group B

I
f] n,tel MLA/ MLc/ Municipal councinor

I t"n.ito* Qro [fian

l-l ffeaO of Recognized Educational lnstitution t;lit:;-';1,,n"5
I
SuOerintendenU Warden/ Matron/ Head of lnstitulion
fl
Recognized shelter homes/ Orphanages
tl'o b
n rproom"", Signature & Stamp of the Certitier

* To be used
as Proof of ldentify (Pol) onty in speciific cases as mentioned in the list of applicable sJpporting documents.

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