Application Form for Domicile Certificate

1. Salutation*: __________

2. First Name*: ______________________________

3. Middle Name: _____________________________

4. Last name*: _________________________________

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

7. Date of Birth*: ______________ Age____________

8. Gender*: ______________

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: ____________________________

Applicant’s Details

Permanent Address of Applicant

Photograph

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: ________________________

33. Father / Husband: _______________

34. Salutation*: _________

35. First Name*: ________________________________________________________

36. Middle Name: _______________________________________________________

37. Last name*: _________________________________________________________

38. Occupation: ______________________________________________

39. Address Line 1*: ________________________________________________________

40. Address Line 2: _________________________________________________________

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

Present Address of Applicant

Father / Husband’s Details

Applicant’s Place of Birth

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: ____________________________________

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

Srl Address Rural/

Urban

Sub-

division

Block/

Municipality/

Corporation

Name

PIN PO PS District State Country House

Type

52. Applicant Details of Business/Service: ________________________

53. Applicant’s Native District: ________________________

54. Applicant’s Native State: ______________________________

Education Details of Applicant

Particulars of Stay of Last 15 Years

Other Details

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: __________________________