FORM OF APPLICATION FOR FINANCIAL ASSISTANCE FOR PARTICIPATION IN INTERNATIONAL SPORTS/EVENTS/ CHAMPIONSHIP/TOURNAMENT/COMPETITION 01. NAME OF THE APPLICANT .. (in Block letters) 02. FATHER'S/HUSBAND'S NAME .. 03. DATE OF BIRTH .. Year .... Month ..... Day ..... Age ... 04. PERMANENT ADDRESS .. 05. PRESENT ADDRESS .. 06. OCCUPATION .. (In case employed in Govt./Private Sector/Public Undertaking/Sector) (I) NAME OF THE EMPLOYER .. (II) DESIGNATION .. (III) PLACE OF EMPLOYMENT .. (IV) MONTHLY EMOLUMENT.. 07. NAME OF THE INTERNATIONAL SPORTS EVENTS IN WHICH HE OR SHE WILL PARTICIPATE (I) DISCIPLINE .. (II) TOURNAMENT/CHAMPIONSHIP/ .. COMPETITION (III) VENUE .. (IV) DATE.. (V) DURATION .. (VI) NO. OF PARTICIPATING COUNTRIES .. (VII) NAME OF THE INTERNATIONAL BODIES .. (APPROVED BY I.O.C.) 08. DETAILS OF LOWER LEVEL PARTICIPATION The information furnished above should be supported by attested photocopies of the documents from the concerned/competent bodies 09. QUANTUM OF FINANCIAL ASSISTANCE REQUIRED : Rs..... (SUPPORTING DOCUMENTS OF SELECTION & PARTICIPATION FROM THE CONCERNED NATIONAL FEDERATION MUST BE ENCLOSED) (Details to be indicated) S L DISTRICT/STA TE LEVEL COMPETITION / TOURNAMEN T/ CHAMPIONSHI P DATE & VENU E PERFORMA NCE NATIONAL LEVEL COMPETITIO N/ CHAMPIONS HIP/ TOURNAME NT DATE & VENU E PERFORMA NCE 1 2 3 4 5 6 7 Place Signature of the Applicant Date UNDERTAKING I do hereby undertake to state that, the information furnished above are true and that I am a permanent resident of State of Orissa further undertake that, incase of nonutilisation of financial assistance sanctioned by the Government in my favour for participation in the concerned Tournament/Championship due to cancellation of the said Tournament/Championship or otherwise, I shall be liable to refund the said amount of assistance to Government forthwith. Place Signature of the Applicant Date Certified that, the information furnished by Sri/Kum .............. are true and in case any of the information is found wanting or false, the Association in the capacity of Sponsoring Agency shall be held responsible for any action as deemed fit by the Government. I do hereby undertake that, any amount of financial assistance sanctioned by Government in favour of the applicant, if not utilised for the concerned participation in tournament, the said sanctioned amount will be returned to Government forthwith. Place Signature of the Hony. Secretary Date ....... Association
