Samaj Sadan Booking Form

Grih Kalyan Kendra — Application Form for Booking of Samaj Sadans

Fields marked * are mandatory. Uploads: JPG/PNG (photos, signatures) and JPG/PNG/PDF (documents).

1Applicant

Name of Applicant *

Category of Applicant *

Central Govt. Servant

State Govt.

PSU

Private

2Employment Details of Applicant

Designation

Mandatory for government categories.

Office Tel. No.

Office Address

Identity Card No. / PPO No. (retired Central Govt. employee)

Scanned Copy of Identity Card / PPO

JPG, PNG or PDF, max 5 MB.

Aadhaar / PAN Card No.

Scanned Copy of Aadhaar / PAN Card

JPG, PNG or PDF, max 5 MB.

Tel. No. (Res.)

Mobile No. *

10-digit number; used to check your application status.

Email (optional)

3Booking Details

Name of the Samaj Sadan Required *

Required From (Date) *

Required To (Date) *

Purpose for which Required *

Purpose Details

Name of the Family Member (function of other than applicant)

For a marriage / birthday / other function of a family member.

Relationship with the Applicant

Photo / Proof of Dependency (CGHS / Aadhaar / PAN Card)

JPG, PNG or PDF, max 5 MB.

4Photo & Signature

Photo of the Applicant *

JPG or PNG, max 2 MB.

Signature of Applicant *

JPG or PNG, max 2 MB.

5Undertaking from Employer

To be obtained by the applicant from his/her employer: “It is certified that the information filled by the applicant is found correct as per the office record of the organisation.”

Forwarding Officer Name

Designation

Telephone No.

Signed Undertaking (scanned)

JPG, PNG or PDF, max 5 MB.

I declare that the information given above is true and correct to the best of my knowledge. *

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