GRAM : JIVABANDHU Phone : 044-2457 1024

044-2457 1025
Fax : 044-2457 1016

ANIMAL WELFARE BOARD OF INDIA

(Ministry of Environment and Forests, Govt. of India)
Post Box No. 8672
13/1, Third Seaward Road, Valmiki Nagar, Thiruvanmiyur, Chennai - 600 041.
Website: www.awbi.org Email : awbi@md3.vsnl.net.in

REGISTRATION FORM FOR ISSUING ID CARDS FOR COLONY CARE TAKERS

Name :
(Please fill in Capital letters) PHOTO

Age (as on 1.1.2013) :

Complete Address with Pincode :

Contact No. :

Provide any one :

Self - attested true copy of the Ration
Card/ Voter ID/ Driving License/ Pass
Port/ Pan Card, with two passport
sized photos

I _________________ S/o or D/o or W/o _________________ do hereby declare that the

details given above are true to the best of my knowledge.

Date :

Place: Signature of the Applicant

(For Office Use Only)

1. APPLICATION No.:

2. Date of Receipt :

3. Date of Issuance of Card: