OFFICE OF THE DEPUTY COMMISSIONER

APPLICATION FORM FOR ISSUING OF DEPENDENT CERTIFICATE

Office where the Application has to process

Select the office where the Application has to Process *

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District Office *

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ADC Office *

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SDO Office *

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EAC Office *

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CO Office *

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Applicant Details

Salutation of Applicant *

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1. Name of the Applicant *

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Mobile Number *

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Salutation of Person *

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2. Name of person for whom certificate is required *

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Does your Guardian is your parent ? *

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Yes

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Salutation *

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3. Name of Father / Husband / Mother *

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Father's / Mother's Occupation type *

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Salutation of Guardian *

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4. Name of the Guardian on whom the person at Sl. No. 2 is dependent

5. Relationship of person at Sl. No.2 with Guardian at Sl. No. 4

Photograph of person for whom certificate is required * Image should be in range of 5KB to 250 KB with allowable formats JPG / PNG

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Address Details of the Person for whom the certificate is required

6. Permanent Address

Village / Sector / Colony *

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Post Office *

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Police Station

State *

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District *

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Circle *

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THIS LABLE IS GOING TO HIDE

If The Present Address is Same as Permanent Address

7. Present Address

Village / Sector / Colony

Post Office

Police Station

State *

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District

Circle *

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Circle Office Permanent

Circle Office Present

Certificate Related Details

8. Purpose for which Certificate is Required *

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9. Occupation of Guardian *

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10. Contact No of Guardian *

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In case of Others

Declaration

I do hereby declare that the above particulars are true and correct to the best of my knowledge and belief and in case of any false statement / information shall be liable for any action under appropriate section of law.

I Agree *