APPLICATION FOR ADMISSION INTO STATE HOME APPENDIX (to G.O.Ms.No.66 of WD, CW &DW (Prog.) Dept. Dt.16.10.99) ANNEXURE - I (See Rule 8) FORM OF APPLICATION FOR ADMISSION INTO RASHTRA SADAN 1. Name in full (in Block Letters) : 2. (a) Present Address : (b) Permanent Address : 3. Date of Birth and Age : 4. Caste & Religion (State whether SC / ST / BC) : 5. (a) Name of Guardian and Address (b) Nature of relationship to the applicant : : 6. Whether candidate is unmarried / married / deserted / widow (if deserted a certificate from a responsible person who will guarantee that the husband will not interfere with the candidate during her stay in the institution / should be furnished) : 7. Whether recommended by the Police / Judicial Magistrate / Medical authorities / Superintendent of Rescue Home. : 8. Whether she is involved in any Court case. : 9. Whether accompanied by Child / Children under 5 years of age if so name, age and sex of the child / children. : 10. Educational qualifications : 11. Training course that the candidate desires to taken Tailoring / 7th class or Matric classes etc. : 12. Name of 3 individuals who are likely to visit her during her stay in the home and the nature of their relationship with the candidate : 13. Any other information that the applicant wants to furnish : 14. Identification Marks : 1. 2. I declare that the particulars furnished above are correct to the best of my knowledge and belief. I also declare that I shall aside by all the rules of the HOME. DATE: SIGNATURE OF THE APPLICANT NOTE:This certificate will have to be signed only in the of applicant who has a guardian and not to total orphan. FOR OFFICE USE 1. Name of the Departmental Officer, who recommended the case for admission. 2. Name of the P.D., DW & CDA / Investigator, who interviewed the candidate. 3. Remarks of the P.D., DW & CDA / Investigator. 4. Date of admission. 5. Admission No. of the candidate (inmate) as entered in the register. SIGNATURE OF THE OFFICER
