Schedule-C
FORM RO. 1 (Clause-4)
Government of West Bengal
Application for Ration Card
Applicants name .... vm Address :
Name of the Head of the family .
Si. Name ofthe [Age [Relationship] “Name offather/ | Occupation | Whether [Immediate] Reason fornon- | EP Shop
No. |member for whom] with the | husband! parents Indian | previous | possession of R/ | No. desired
Ration Card is Head of | (incase of mantied Citizen | “address | Card (im absence
required family woman) (ifany) | of Surrender
Certificate)
1 2 3 4 5 6 7 8 9 1
1. Proofof Residence: Municipal/Panchayat Tax Receip/Rent Receipt’ | 1 solemnly afliem that
Electric Bill/Telephone Bill/Certificate from local elected | the above statements
Documents to be Representative for completely new Ration Cards ofall the members | are truc to my knowl-
attached ‘of family or Ration cards against surrender certificate edge and belief,
eens 2. Proof of Age : Birth Registration Certificate /School Certificate!
a ‘any authorised document indicating the age of members.
Possessin/Non-possession Certificate: Surrender Certificate along
‘with cancelled Ration Cards indicating possession of Ration Card/
certificate by a member from the elected representative ofthe locality
‘where the person previously resided.
Proof of Citizenship: EPIC of self, parents or grand parents/Passport!
Electoral Roll/Employment Exchange Registration Card/any Govt.
Licenee/any other relied document which only an Indian Citizen
can have.
Receipt SiNo. Returnable Date:
& Date
Signature of the Receiving Official