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APPLICATION FOR NEW FOOD SECURITY CARD

Head of the Household Details


Card Type*:  FSC
UID (Aadhaar)*: ________________________ Name of Head of the Family*: __________________
HOF Father / Spouse Name*: _________________
Age*: _____________________________

Social Status*:  General

Gender*: Male Female Transgender

Religion*: _________________________________

 BC  SC  ST  OTHERS

Gas Connection Details


If Gas Connection is available:  YES

Gas Connection Status*:

 NO

 Deepam

Gas Company Name*:  BPCL

 Double

if YES
 No Cylinder

 Single

HPCL  IBP  IOCL  NA

Gas Agency Name *:______________________________________________________________


Consumer No*: _____________________________________

Residence Address
Door Number*: _____________________ Locality/Landmark*: __________________________
District*: ____________________________ Mandal*: ________________________________
Village/Ward*: _________________________ Pin Code*: ______________________________
FP Shop No*: ___________________________

SKS Form No: ___________________________

Add Member Details (Including HOF) *


AADHAAR NO.

EID

MEMBER NAME

SRDH NAME

AGE

GENDER

HOF

SRDH STATUS

RELATION WITH HEAD

YES/NO

Informant Details:
Informant Name*: _______________________

Informant Relation *: ______________________

Mobile No*: _________________________ Aadhaar Proof Document*: ____________________


Address Proof Document*: _________________________________
Delivery Type*: Manual  Local post
 Non Local post

Documents List:
(NOTE: 1.Total size of Upload Document should not exceed 3 MB.2. All Upload Documents should be in PDF Format Only)

1.
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3.

Application Form*
Aadhaar Proof Document*
Address Proof Document*

Applicants Signature