RTI Application Form FORM 'A' See Rule 3(1) I. D. No....... (For Office Use Only) To The Public InformationOfficer/ Assistant Public InformationOfficer 1.FullName ofThe Applicant : ____________________________ 2.Father Name/Spouse Name : ____________________________ 3.Permanent Address : ____________________________ : ____________________________ : ____________________________ 4.Correspondence Address : ____________________________ : ____________________________ : ____________________________ 5.Particulars ofThe InformationSolicited a) SubjectMatter ofInformation(*) : ____________________________ b) The period towhichinformationrelates(**): ____________________________ c) Specific DetailsofInformationrequired (***): ____________________________ d) Whether informationisrequired byPost : ____________________________ orinperson(the actualpostalfeesshallbe : ____________________________ included inadditionalfee inproviding the information) e) Incase byPost(ordinary/registered : ____________________________ or speed post) 6.Is this informationnot made available by public authorityunder voluntarydisclosure? : ____________________________ 7.Doyou agree to paythe required fee? : ____________________________ 8.Have you deposited applicationfee? : ____________________________ (IfYes,Detailsofsuchdeposit) : ____________________________ 9.Whether belongs to below PovertyLine category? : ____________________________ (Ifyes, you furnished the proofofthe same with application?) Place: Signature ofApplicant Date: (*) Broad Categoryofthe subject to be indicated (suchas grant ofgovernment service matters/Licenses etc.) (**) Relevant period for whichinformationis required to be indicated. (***) Specific details ofthe informationare required to be indicated. Name ofthe Department or Public Authority FORM "B" [See rule3 (2)] Acknowledgement Office ofthe State Public InformationOfficer Received the application formfrom Mr/Ms : ____________________________ Address : ____________________________ : ____________________________ : ____________________________ Seeking information on(Subject to be specified) : ____________________________ : ____________________________ : ____________________________ Vide DiaryNo.: ____________________________Dated:_________________________ Place Date FullName ofState Public InformationOfficer/ State Assistant Public InformationOfficer Designationand Seal
