Professional Documents
Culture Documents
(For EX-SERVICEMENIWIDOW ,
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Please read instructions carefully before filling Application Form (Restricted when completed). To be Filled in Original, No Photostats Allowed
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number of Canteen Cards applied for through Cheque I Draft Number Bank
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Branch,
~ Signature & Stamp of Competent Authority,
Date:
Permanent Address
City Tel'No:
Dependent Details
Dependent 1 Details Name (Please leave blank box for space)
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Daughter
Date of Birth:
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CERTIFICATE
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Dependent's Signature Payment Details (To be filled by URC) Received withthanksa sumof Rs. I I I I forD numberof Canteen Cardsapplied forthroughCheque drawnan Bank Branch. Personal No
Certified that all information given above is correct to best of my knowledge. I am liable for disciplinary 1 legal action including , cancellation of Liquor 1 Grocery Card at any point of time, if the information furnished by me-is found incorrect or the CSD facility is misused by me. Station: Signatufl'>'of Date: Primary AppHcant
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/ DraftNumber
Date:
COUNTER SIGNED Certified that applicant is lffi Ex-serVioemeR e~ti\led canteen facilities & aI/ information has been vetted as correct to best of my \<nowl.edge. A" SupportingDocument&are r~ned. In case of re-aJ.'Plying. old Smart Card will.be destroyed by punching at this URC before handingover new cards. PPO/Discharge Doc~ No.. '~ .. , Issued by has been verifted-& found correct, . Round Stamp: Date: Sianature & Stamo of Canteen Manaaer
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SANOTtON Of HIGHER AUTHORITY Certified that applicant is an Ex-servicemen entitled canteen facilities & all information provided is verified. Personal & Nameotthe Higher AUthority PPO/Discharge Document No: Dated Signature & Stamp of $tn. HQlRSB/KSB lssuedbv has beert'verifled ~ found 'correct. (Officer not below Lt. Colonel/Equivalent)
No.