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'-CANTEEN SMART CARD APPLI,CATION FORM(For EX-SERVICEMENIWIDOW Only) '", ' E rrors or B lanks will be Re

Please read instructions carefully before filling Application Form (Restricted when completed). To be Filled in Original, No Photostats Allowed, [,] A p p lic a tio n N um b epa ste~ ::~ !~~~sport pa st::r~:o :E!out ~____________ I ,SE

Si ze Photo without head gear wit h spouse Sign in sid e t he bo x (PrimaryApplicant on ly) 1 6 ( ) 5 3 0h ea d g ea r. ( no s ep ara te Photos ) Applying 1st time0 )P le ase P aste. Don't Staple 0

' PleasePaste.Don'tStaple *Reapplying1 . . . - - - ' (Ifapp lyingforb oth categories, use tw o sepa rat e forms) IURC No. DDDDDDDDDD For use of URC St~f onlyCDI ~~ CIIIIJDCDCDRC NameS,erviceCategory of Applicant

ArmyD~SMD

NavyD,Widow/NOK D

J COD

Airforc~ D *Others D ("A1soSpe~ifytheParentServiceCategory Officer DCard(s) "'Combined Grocery D'Applied for Cum Liquor

OR oD *Dependent1 D("Not Authorized 'with combined card) *Dependent2 D("NotAuthorizedwith combined card)Liquor D Grocery

*In case of Reapplying enter ,, Old Uq uor I Grocery Card Id '------'l.---1-----A_-'---L---L--''--..L--+-.----'-_-'---'----'---''--..L--''----''-_lL--JPersonal Number ' DDDDDDDDDDDDDDDName infull (P lease leave b lank box fo r space ) DDDDDDDDDDDDDDDDDDD DCDRank

Date of Birth: (DD/MMIYYYY) o=J en ~Date of Commissioning I J Oining ( D D /M M IY Y Y Y ) o=J o=J ~Date of Retirement: (DD/MMIYYYY) o=J o=J ~Pension Pay Account Number (PPO Number)if allotedIdentification Mark I I I __L--L__L-~__ -~ __ ~~~~ __ L--L__L-~__~~ __~~Qender: Male D FemaleDMarital Status: Married D Unmarried D Divorcee D Widow I Widower DSpouse Name DDDDDDDDDDDDDDDDDDDDDDApplicant Mobile No. DDDDDDDDDDApplicant Father's NameDDDDDDDDDDDDDDDDODDDDD--------------------------,---~------------------

Appl ica tion NU l)1berSE

Receivedwith thanks a sum of Rs,UTI from Personal Nt-6 8 5 S O dforD numberof Canteen Cards appliedfor through Cheque I DraftNumber drawn on -_________ Bank Branch,Date: Signature & Stamp ofCompetentAu- ~!

RECEIPT,

7/27/2019 Special Sanction for car

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PermanentAddress

CityTel'No:Dependent DetailsDependent 1 DetailsName (Please leave blank box for space)

Relation with Primary Applicant: sonO Daughter 0FatherDate of Birth: (DD/MMIYYYY) [TI [TILIID

(Please leave blank box for space)

o Mother 0ATTESTEDDependent'sPhoto

U se G um. Don't taple

r - - - - ' - - . - . ~ - . . . . .- . . - - - - . . . .~!IL - - .

Dependent'sSignature'- - - - - - - - - - - - ~- - - - - ~- - - - - - - - - - - - - - - - - - - - - - - - - - - -ependent 2 DetailsName (Please leave blank box for space) ATTESTEDDependent'sPhotoU se G um. Don'tS taple

Relation with Primary,Applicant: Son 0Daughter DFather 0Mother DDate of Birth: (DD/MMIYYYY) .[TI [TILIIDIdentification Mark (Please leave blank box for space)I I I I I I I I I ~ i I I I I ~ I I I I .~.. " ". " ..Dependent's Signature

CERTIFICATE For URC use only Payment Details (Tobe filled by UCertified that all information given above Forwarded for personalisation of cards ReceivedwiththanksasumofRs. I Iis correct to best of my knowledge. I am from PersonalNo foliable for disciplinary 1 legal action including to S CL on (Date) numberofCanteenCardsappliedorthroughcancellation of Liquor 1Grocery Card at ,any point of time, if the information furnished / DraftNumber dby me-is found incorrect or the CSD facility Bankis misused by me.Station: Signatufl'>of Signatureand Stamp Signature& StampofCompetentuthorityaate: ;- PrimaryAppHcant Date: ApprovingAuthorityat URC

COUNTER SIGNEDCertified that applicant is lffi Ex-serVioemeR e~ti\led canteen facilities & aI/ information has been vetted as correct to best of my \