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WBeDistrict Domicile Certificate Application Form

The document is an application form for a domicile certificate. It requests personal details of the applicant such as name, date of birth, gender, identification details, contact information, as well as permanent and present addresses. Additional sections gather details on the applicant's father/husband, place of birth, education history, residential history for the past 15 years, and reasons for applying. The applicant must provide their signature and date, as well as list documents being submitted to support the application.

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Himani
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352 views4 pages

WBeDistrict Domicile Certificate Application Form

The document is an application form for a domicile certificate. It requests personal details of the applicant such as name, date of birth, gender, identification details, contact information, as well as permanent and present addresses. Additional sections gather details on the applicant's father/husband, place of birth, education history, residential history for the past 15 years, and reasons for applying. The applicant must provide their signature and date, as well as list documents being submitted to support the application.

Uploaded by

Himani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application Form for Domicile Certificate

Applicants Details

Photograph
1. Salutation*: __________

2. First Name*: ______________________________

3. Middle Name: _____________________________

4. Last name*: _________________________________

5. Mobile No.:____________________ 6. Email: _________________________________

7. Date of Birth*: ______________ Age____________

8. Gender*: ______________

Permanent Address of Applicant

9. Address Line 1*: ________________________________________________________

10. Address Line 2: _________________________________________________________

11. Rural / Urban*: _________________12. Sub-Division: ______________________

13. Block/Municipality/Corporation*: ________________________________

14. Block/Municipality/Corporation Name*: _____________________________________

15. PIN Code*: ___________

16. Post Office: _________________________ 17. Police Station: ________________

18. District*: ______________________

19. State: ________________________

20. Country: ____________________________


Present Address of Applicant

21. Address Line 1*: ________________________________________________________

22. Address Line 2: _________________________________________________________

23. Rural / Urban*: __________________ 24. Sub-Division: ______________________

25. Block/Municipality/Corporation: ______________________________

26. Block/Municipality/Corporation Name*: _____________________________________

27. PIN Code*: ____________

28. Post Office: __________________ 29. Police Station: _______________

30. District*: __________________

31. State: _________________________

32. Country: ________________________

Father / Husbands Details

33. Father / Husband: _______________

34. Salutation*: _________

35. First Name*: ________________________________________________________

36. Middle Name: _______________________________________________________

37. Last name*: _________________________________________________________

38. Occupation: ______________________________________________

Applicants Place of Birth

39. Address Line 1*: ________________________________________________________

40. Address Line 2: _________________________________________________________

41. Rural / Urban*:________________ 42. Sub-Division: ______________________


43. Block/Municipality/Corporation: ______________________________

44. Block/Municipality/Corporation Name*: _____________________________________

45. PIN Code*: ____________

46. Post Office: __________________ 47. Police Station: _______________

48. District*: __________________

49. State: _________________________

50. Country: ________________________

51. Details of Parents Business/ Service: ____________________________________

Education Details of Applicant

Srl Level Name of Institution Class From Class To From Year To Year

Particulars of Stay of Last 15 Years

Srl Address Rural/ Sub- Block/ PIN PO PS District State Country House
Urban division Municipality/ Type
Corporation
Name

Other Details

52. Applicant Details of Business/Service: ________________________

53. Applicants Native District: ________________________

54. Applicants Native State: ______________________________


55. Duration of stay in West Bengal (in Years): _______

56. Whether Applicant / Parents possesses any immovable property in West Bengal: _______

(Yes/No)

57. Specify immovable property details, if yes: _______________________

58. Reason for Application: ________________________________

59. Other Reason for Application (if any): _______________________________________

60. List of Documents: A. Residential Proof: _____________________________________

B. Identity Proof: ________________________________________

C. Birth Proof: __________________________________________

I hereby declare that the above information is true to the best of my knowledge and belief.

Signature: __________________________________

Date of Application: __________________________

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