Form 1A(See Rule 3) - e-District Kerala
Form 1A (see rule 3)
Application form for availing Public Grievance Services
Language in which the service is required : □ English □ Malayalam
e-District Registration Number if any: ……………….
| Part I (General Details for one time registration in e-District portal) |
1. Name of person for whom service is sought * …………………………………………………….................................
2. Gender (M/F) * ………………………………………………………….
3a. Age *: …............. 3b. Date of Birth ………………………………(DD-MM-YYYY)
|Details |4. Present Address |5. Permanent Address |
|House No *: | | |
|House Name *: | | |
|Street / Place *: | | |
|Post Office *: | | |
|PIN code *: | | |
|Village *: | | |
|Taluk *: | | |
|District *: | | |
|Name of Local Body *: | | |
|Type of Local Body * □ Grama Panchayat □ Municipality □ Corporation |
6. Name of Father *: .............. OR Name of Mother *.................. OR Name of Spouse *……... OR Name of Guardian *:.........
7. Phone (Res.): Code:………… Number: ..................................... 8. Mobile: .........................................................................
9. Email: ………………………..................................................................................................................................................
10. Ration Card No: ………………........................................ 11. Driving License No: ..…………………..........................
12. Election ID Card No ………………...………………….. 13. Passport No: ………………………….............................
14. Adhar No (UID) : ………………...…………………..
15 SSLC Registration Number: ..................... / Year..............
|Part II K (a) - Grievance details |
|Grievance Program (Departmental / JSP/Sutharyakeralam) | |
|Subject of Grievance | |
|Name of Department | |
|Name of Office | |
|Details of Grievance | |
| | |
| | |
| | |
|Part II K (b) - Previous Reference details (if any) |
|Reference Number | |
|Date | |
|Name of the Department of the Reference Application. | |
|Name of the Office of the Reference Application. | |
|Remarks | |
Enclosures: ..........................................................................................................................................................................
…......................................................................................................................................................................
DECLARATION
I do hereby certify that the particulars mentioned above are complete and true to the best of my knowledge and belief. I also agree that any loss to Government due to the Incomplete or Incorrect information provided above may be recovered from my movable/ immovable assets. I also agree that the grievance reply so issued and any benefits accrued in lieu of that stands nullified on proved mis-representation.
Place : …................................................................. Signature : …............................................................................................
Date: …................................................................... Name of Applicant : ….............................................................................
Relationship with the person for whom service is applied for
: …..............................................................................................................
(Relationship to be specified if the above declaration is signed by Parent / Guardian / Authorized Representative)
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