Applicant Photo

BENEFICIARY APPLICATION FORM

1. Date of Application : ________________________________

2. Name of Applicant : ________________________________

3.Father/Husband Name : ________________________________

4. District : ________________________________

5. Sub-division : ________________________________

6. Block : ________________________________

7. Gram Panchayat : ________________________________

8. Village : ________________________________

9. Revenue Thana No: ___________

10. Gender : I. Male II. Female (put a tick mark)

11. ID No (Voter ID card) :________________________________

12. Category : (a) General (b) SC (c) ST (d) Minority (e) EBC (f) BC

13. Mobile No : ________________________________

14. Account No. /RTGS Account No. : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

15. Name of the Bank : ________________________________

16. Branch Name : ________________________________

17. IFSC Code : ________________________________

18. Name of Scheme : ________________________________

19. Name of Implement : ________________________________

20. Implement Make & Model : ________________________________

21. Subsidy Received by : I. Self II. Dealer (put a tick mark)

22. Malgujari Receipt No. _______________________

23. Applicant Land Details:

Khata No. Khesra No. Rakva(in acre)

24. Details of last Purchased Five Implements in subsidy scheme:-

SNO. Implement Name Year Of Benefit

ii

iii

iv

Declaration by Farmer:-I am a bonafied progressive farmer .All the above informations are true
to the best of my knowledge and based on evidence and record. The Implement/Machines
applied for are not purchased earlier in subsidy scheme by me or my family members. If found so
I will be punished and criminal proceeding may be drawn against me or my family members. I
will produce each and every related original document before enquiry officers
(BAO/DAO/AgricultureEngineers).

Tick here if you agree...

Applicant Signature