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.
2.
3.

Application Form*
Aadhaar Proof Document*
Address Proof Document*

Applicants Signature