DATA FORM

DATA FORM
(To be filled in Block letters only by those who have attained 18 years of age as on 01-01-2008)
CENTRE CODE: SL.NO:

MASTER SRL.NO:
NAME OF APPLICANT:
DATE OF BIRTH:
AGE:
SEX: MALE / FEMALE
MARITAL STATUS: MARRIED / UNMARRIED.
NUMBER OF ISSUES: SON: DAUGHTER:
VOTER CARD NO:
WARD WHERE VOTED LAST:
OCCUPATION: TRADER / CONTRACTOR / PROFFESSIONAL / SERVICE - GOVT./PRIVATE / RETIRED.
QUALIFICATION:
Attach at least one certificate
CONTACT INFO.: LANDLINE: MOBILE: E.MAIL:
NAME OF FATHER / HUSBAND:
NAME OF GRAND FATHER OF SELF/HUSBAND:
NAME OF GREAT GRAND FATHER OF SELF/HUSBAND:
NAME OF EARLIEST FIRM:
YEAR OF ESTABLISHMENT:
NAME OF PREVIOUS EMPLOYER (IF ANY):
NAME/ADDRESS OF THE CURRENT FIRM OR EMPLOYER:
LAND MARK:
PRESENT RESIDENTIAL ADDRESS:


LANDMARK:
YEAR OF ESTABLISHMENT OF CURRENT FIRM:
NAME OF FAMILY MEMBER WHO CAME EARLIEST:
YOUR RELATION WITH SUCH PERSON:
YEAR :
EARLIEST DOCUMENT AVAILABLE:

DOCUMENTS ENCLOSED:
Verification:

I ………………………………………………………………………...…
s/o-d/o-w/o:………………………………………………………………………..
do hereby declare that whatever stated above is true to the best of my
knowledge and belief and nothing is false or misrepresented.
PLACE:
DATED:

SIGNATURE OF APPLICANT
Please Turn Over.

Brief History of your family in Sikkim:

Your contribution to the State of Sikkim in the field of :
Education:
Art and Culture:
Spiritual and Religion:
literature:
Philantrophic:
Charity and sponser:
Social Projects:
Publications:
Sports and Games:
Politics:
Others:

Name/s of Associations and N.GO.'s with whom associated and for how many years.
a
b
c
Any Awards / Appreciation received from Panchayat / Local Bodies / Government / N.G.O's /
national or international:
a.
b.
c.

Any other matter you want to specify:

SIGNATURE OF THE APPLICANT.
------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY.
DATE OF RECIEPT:
ENTERED IN THE REGISTER VIDE SERIAL NO:
SIGNATURE OF THE RECIEVER
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