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PROFORMA II

Please read the instructions on the reverse side * Use one box for one alphabet only
of this Proforma carefully and fill in all particulars * Leave one box blank after each word
in the BOXES IN ENGLISH (BLOCK LETTERS * Do not split the word
ONLY) * Use next line
From: Thiru / Selvi / Thirumathi

Residential Address :

District : Pin :
Thiru / Selvi / Thirumathi (Hindu / Christian / Islam)

Son / Daughter / Wife of Thiru :

To be published in the Tamil Nadu Government Gazette.


Born on Date Month Year

Native District :

Residing at :

has converted / reconverted to Hinduism / Christianity / Islam with the name of

on
(i) Signature.............................................................
Station : (As in the column of Old Name)

Date : (ii) Signature of parent or guardian (if parents deceased) in


the case of minors with relationship in BLOCK LETTERS.
Declaration
(i) I hereby declare that I belongs to Scheduled Caste or Backward or Most Backward Class reconverted from Christianity to Hinduism.
(ii) I hereby declare that I am a native of Tamil Nadu and residing
permanently in Tamil Nadu. (i) Signature...................................................................
(As in the column of Old Name)
(iii) To prove the nativity, a certificate issued by the Tahsildar (or)
Xerox copy of Ration Card should be enclosed. (ii) Signature of parent or guardian (if parents deceased)
in the case of minors with relationship in BLOCK LETTERS.

WITNESS
The information furnished above are correct and true to the best of my knowledge and belief.

...................................................................... ......................................................................
Name of the Witness in BLOCK LETTERS Signature of the witness
Status / Occupation and Address........................................... (The witness should be in Gazetted of
................................................................................................ Tamil Nadu Government /
................................................................................................ Central Government Officers with seal.)

[P.T.O.
DTP—373-63—10,000—10-2-06—[P4-17-E]
2

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ñ£Ÿø‹ ªêŒòô£‹.
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ªðøŠð†ì «è£®†ì «è†¹ õ¬ó«õ£¬ô (Demand Draft) Íô‹ ÜŠð «õ‡´‹.

This Proforma is intended for the Change of Name and Religion only

INSTRUCTIONS

1. The application and the notice for change of name, etc., must Demand Draft drawn in any nationalised bank in favour of the
be from the person who wishes the name to be changed duly signed by Assistant Director (Publications), Commissionerate of Stationery and
him with a witness from an “A” or “B” Grade Officer of Tamil Nadu Printing, 110, Anna Salai, Chennai-600 002. Publication charges by
Government/Central Government not related to the applicant and should means of Money Orders and Postal Orders will not be accepted.
contain his/her address and no correspondence will be entered into with
5. Five copies of Gazettes in which the change of name, etc., was
any other person than the person who wishes his/her name to be
published will be sent to the concerned person by Registered Post. Any
changed. The present name (Old name) and signature are to be identical.
more copies required will have to be purchased by the person from the
2. In the case of minors whose name is to be changed, the parent Assistant Director (Publications), Commissionerate of
or guardian (if parent deceased) should sign the notice for change of Stationery and Printing, 110, Anna Salai, Chennai-600 002 on separate
name. He/She should write the name in capitals below the signature and payment.
also mention the relationship with the individual who changes the name
6. No reminders to the party either for remittance or for any other
and religion.
particulars will be sent.
3. Notice for a change of name and religion will be entertained only 7. Xerox copy of the Proforma will not be accepted.
in respect of persons who are natives of this State for which they should
give a declaration in the notice. There should be no correction in the Note:
notice. (1) This Proforma is intended to publish the change of name
together with the change of one religion to another religion. If the party
4. The charges for publication of change of name and religion
desires to publish the change of name only, a separate Proforma
including the cost of five copies of Gazettes and postage charges are
(Proforma-I) is available and will be sent on application.
Rs. 415/-. The same may be paid either at Cash Counter of this office
between 10.00 am. to 1.00 p.m. and 2.00 p.m. to 3.00 p.m. or sent to (2) The original religious reconversion certificate issued by the
the Assistant Director (Publications), Commissionerate of Stationery and religious authority or a certified copy of it should be sent with this
Printing, 110, Anna Salai, Chennai-600 002 in the form of proforma for the reference of this office.

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