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Affix one recent

passport size
photograph

Court Fee Stamp as required

APPLICATION FORM FOR PERMANENT RESIDENT CERTIFICATE


(For Education or Service purposes only)
(Fieldsmarked*aremandatory)
NameofApplicant*

:- ___________________

Name of Spouse

:- ___________________

Gender*

:- ___________________

DateOfBirth*

:- ___________________

NameofFather*

:- ___________________

Name of Mother

:- ___________________

Age*

:- ___________________

Nationalilty*

:- ___________________

District*

:- ___________________

SubDivision*

:- ___________________

RevenueCircle*

:- ___________________

Village/Town*

:- ___________________

GP/Ward

:- ___________________

Mouza

:- ___________________

PoliceStation*

:- ___________________

PostOffice

:- ___________________

91

Mob. No.

91

Address of the Applicant :

Pin No.
Phone No.

(STD Code without 0 prefix +


Phone No.)

(10 Digit Mobile No.)

e-mail ID,if any :- __________________


Howmanyyearsresidedintheaboveaddress?*:- ___________________

Details of the land possessed by the Applicant/Father/Mother/Husband


District*

:- ___________________

SubDivision*

:- ___________________

RevenueCircle*

:- ___________________

Village/Town*

:- ___________________

PattaNo.*

:- ___________________

DagNo.*

:- ___________________

Purpose for which PRC is needed (Tick whichever is applicable)


(Tick whichever is applicable)
1.Education
Admission into higher educational Institutions
2.Service
Paramilitary Forces
Army
Central Govt. Depts & Undertakings

DECLARATION
All the information furnished above are correct to the best of my knowledge and belief.

Date :-

Signature of Applicant

Supporting Documents Required


* In case, each supporting document has multiple pages, please convert the same to a single document, with a file size of less than
2MB(2048 kb) and upload.

1.Passportsizephotograph
2.Admissionform(foreducationpurpose)
3.CallLetter/InterviewLetter/AdmitCarddetails(forrecruitmentpurposes)
4.Anysupportingdocuments
5.1966voterlistalongwithlinkageCertificate/NRC/CitizenshipCertificate
6.LandDocument
7.LandRevenueReceipt(UptoDate)
8.PoliceReportfromconcernedO/CorS.P.