'-CANTEEN SMART CARD APPLI,CATION FORM

(For EX-SERVICEMENIWIDOW ,
paste~::~!~~~sport Size Photo without head gear. Please Paste. Don't Staple ' past::r~:o:E!out head gear with spouse (no separate Photos) PleasePaste.Don'tStaple

Only) [,]

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Errors or Blanks will be Rejected

Application Number

Please read instructions carefully before filling Application Form (Restricted when completed). To be Filled in Original, No Photostats Allowed

0 0 *Reapplying
Applying 1st time --'

~____________ Sign inside the box (PrimaryApplicant only)

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16 ()5 3 04 )

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1...URC No. URC Name

(Ifapplyingfor both categories, use two separate forms)

DDDDDDDDDD
CDI ~ ~
ArmyD ~SMD Officer D NavyD ,Widow/NOK D OR Grocery JCOD Liquor Airforc~ D

For use of URC St~ff only

CIIIIJDCDCD
*Others

S,ervice Category of Applicant Category

D Parent ("A1soSpe~ifythe Service

Card(s) "'Combined Grocery D' Applied for Cum Liquor

o
D
*Dependent1

("Not Authorized with combined card)

D '

*Dependent2

("Not Authorized with combined card)

*In case of Reapplying enter , , Old Uq uor I Grocery Card Id '------'l.---1-----A_-'---L---L--''--..L--+-. ----'-_-'---'----'---''--..L--''----''-_lL--J
Personal Number

Name in full

DDDDDDDDDDDDDDD (Please leave blank box for space) DDDDDDDDDDDDDDDDDD D DCD

'

Rank

Date of Birth: (DD/MMIYYYY) Date of Commissioning Date of Retirement: I JOining (DD/MMIYYYY)

(DD/MMIYYYY) Number (PPO Number)

o=J en ~ o=J o=J ~ o=J o=J ~

__ J-~
__ ~~~~ __

Pension Pay Account if alloted Identification Qender: Marital Status: Spouse Name Mark

I
Male D

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__ L--L __ L-~

L--L __ L-~

__ ~~

__ ~~

FemaleD Unmarried D Divorcee D Widow I Widower D

Married

DDDDDDDDDDDDDDDDDDDDDD DDDDDDDDDD DDDDDDDDDDDDDDDDODDDDD --------------------------,---~------------------Applicant Mobile No.

Applicant Father's Name

ApplicationNUl)1ber RECEIPT, Received with thanks a sum of Rs, forD

UTI

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Personal Nt-6

from

8 5 SOd
_

number of Canteen Cards applied for through Cheque I Draft Number Bank
~!

drawn on

_________
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Branch,
~ Signature & Stamp of Competent Authority,

Date:

Permanent Address

City Tel'No:

Dependent Details
Dependent 1 Details Name (Please leave blank box for space)

ATTESTED
Dependent's Photo Use Gum. Don't Staple

Relation

with

Primary

Applicant:

sonO

Daughter

Date of Birth:

(DD/MMIYYYY)

[TI [TI LIID

Father

Mother

0
r----'- -.-.~-...,..- .. ---- ....~.!
L--.
I

(Please leave blank box for space)

II

------------~-----~-----------------------------Dependent 2 Details Name (Please leave blank box for space)

Dependent's Signature'

ATTESTED
Dependent's Photo Use Gum. Don'tStaple

Relation

with

Primary,Applicant: (DD/MMIYYYY) Mark .

Son

Daughter

D
~

Father

Mother

D
.~ ,.. ""."

Date of Birth: Identification

[TI [TILIID
~

(Please leave blank box for space)

I I I I I I I I I
CERTIFICATE

i I I I I

I I I I
from

..

Dependent's Signature Payment Details (To be filled by URC) Received withthanksa sumof Rs. I I I I forD numberof Canteen Cardsapplied forthroughCheque drawnan Bank Branch. Personal No

For URC use only

Certified that all information given above is correct to best of my knowledge. I am liable for disciplinary 1 legal action including , cancellation of Liquor 1 Grocery Card at any point of time, if the information furnished by me-is found incorrect or the CSD facility is misused by me. Station: Signatufl'>'of Date: Primary AppHcant
;-

Forwarded for personalisation of cards to SCL on (Date)

/ DraftNumber

Date:

Signature and Stamp Approving Authority at URC

Signature & Stampof Competent Authority at URC

COUNTER SIGNED Certified that applicant is lffi Ex-serVioemeR e~ti\led canteen facilities & aI/ information has been vetted as correct to best of my \<nowl.edge. A" SupportingDocument&are r~ned. In case of re-aJ.'Plying. old Smart Card will.be destroyed by punching at this URC before handingover new cards. PPO/Discharge Doc~ No.. '~ .. , Issued by has been verifted-& found correct, . Round Stamp: Date: Sianature & Stamo of Canteen Manaaer
! _

--------------~-~---...--,.---------------------------INSTRUCTIONS: (USE BLACK INK ONLY)

1. 2. 3. 4. 5. 6. 7. Aft photographs to be attested by countersigning Authority. '8. Only high resolution photographs will be accepted. Computer (Inkjet)Printouts/ Photostat photos win not be accepted. I One passport .size photograph each (Single & joint) In civil dress to be affixed in given box. Photocopy of PP Order duly attested a Gazetted officer 10 be attached. Dependents as per existing definition. USE BLOCK LETTERS ONLY lIIeglllle and Incomplete documents can be rejected and applicant would be responsible for the same. Mode of PaYlm~nt: AI Cost of one card being Rs.130/-+Rs.51(to URC)to be depositedby applicant.BI URCto pay Rs.130/-per card In favour of SMART CHIP LTD. by DemandDraft. ' Counter Signing Authorityat StationHQ-RS8,KS8for Nominated fmnD~pendent URC. 9. Smart Card(s) will be issued only to applicant in person due'to security reasons. 10. Original PP order if alloted must be produced while collectingthe Smart Card for verification and endorsement. . 11. Proof of residence (House aliotmentIPossessienletterrrelephonebilV Electricity bilVDriving Licence . 12. A copy of Birth Cart/School leaving Cert. showing date of birth of dependent duly attested by Gazetted Offr. . 13. For Widows only: i. Personal Particular will be of deceased husband no photograph. ii: Singl.ephoto only of widow in place of joint photograph. III. Maximumtwo dependents i.e. father, mother,son, daughter.

SANOTtON Of HIGHER AUTHORITY Certified that applicant is an Ex-servicemen entitled canteen facilities & all information provided is verified. Personal & Nameotthe Higher AUthority PPO/Discharge Document No: Dated Signature & Stamp of $tn. HQlRSB/KSB lssuedbv has beert'verifled ~ found 'correct. (Officer not below Lt. Colonel/Equivalent)

No.