(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN) PLEASE READ GENERAL INSTRUCTIONS TO THE CANDIDATES BEFORE MAKING THE APPLICATION. For Office use Not to be filled by applicant D D - M M - Y Y Office Code Serial No Date of receipt of application APPLICATION FOR RAJIV GANDHI GRAMIN LPG VITRAK (RGGLV) OF Particular of application fee Demand Draft Number Please write name of Oil Company of the location (BPC or IOC or HPC) ` Date D D - M M - Y Y Passport Size Photograph with specimen signature partially across the photograph Drawn on In favour of 1 2 3 4 5 6 Advertised on D D - M M - Y Y Y Y in (Please write Name of Newspaper) 7 (name of the bank) Payable ( Full name of the oil company) At (Enclose Application processing fee of Rs1000/ ( one thousand only) for all applicants except SC/ST candidate. Application processing fee for SC/ST candidates is Rs 500/- (Five hundred) on enclosing SC/ST certificate.) Name of the RGGLV Tehsil/Sub-Division/Block District State Category Please attach copy of eligibility Certificate(s) as proof for the respective categories from the competent authorities, as mentioned in the eligibility criteria. Not Applicable for locations under 'Open' category. Applicant should enclose Affidavit as per the format given in Appendix - A 7.1 Name 7.2 Father’s / Husband’s Name 7.3 Address First name Middle name Surname S H R I Title First name Middle name Surname Pin code : Telephone No - email : 7.4 Indian Citizen Yes No Resident of (Name of Village) District (Name of District) State (Name of State) 7.5 Gender Male / Female 7.6 Date of Birth D D - M M - Y Y Y Y Age : Years Months Days Age as on the date of application 7.7 Marital Status 7.8 Name of Spouse (If Married) Single Married Widow Widower Divorcee Strike off what is not applicable. 8 Educational Qualification (Minimum as per Eligibility Criteria) Qualification Board/University Year of Passing Matriculation i.e. Xth Standard examination or equivalent from recognized Board. Name of Location___________ Page 1 of 16 (Signature of applicant)
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