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FORM ‘A’

Application for Information under section 6(1) of the Act

To,

            The State Public Information Officer /

The State Assistant Public Information Officer

            (Name of the office with address)

  1. Full name of the applicant
  2. Father/spouse name
  3. Permanent address with contact Nos.
  4. particulars in respect of identity of the applicant
  5. Particulars of information solicited.
    1. Subject matter of information
    2. The period to which the information relates
    3. Specific details of information required
    4. Whether information is required by post or in person ( The actual postal charges shall be included in providing information)
    5. In case by post ( ordinary, registered or speed)
  6. Address to which information will be sent & in which form.
  7. Has the information been provided earlier
  8. Is this information not made available by the public authority
  9. Do you agree to pay the required fee
  10. Have you deposited application fee ( If yes details of such deposit)
  11. Whether belongs to BPL category, have you furnished the proof the same.

 

Place   

Date                                                                Full Signature of the applicant

                                                                        Address………………………..

                                                                        Contact Nos……………………

 

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Office of the Public Information Officer

Receipt No. …

 

Received the application

From ………………………………………………………………………………………

Address……………………………………………………………………………………

on seeking information.

Place

Date

Full name of State Public Information Officer/

 State Assistant Public Information Officer

   Designation

            Seal