APPLICATION FORM Senior Citizen Identity Card

1 APPLICATION form . Senior Citizen Identity card Fields marked with (*) are mandatory Applicant's Details Name*. Photograph of the person Father's/Husband's Name* ( on whose name Senior Gender* Male Female Transgender Citizen ID card is to be (DD/MM/YYYY) issued). Date of Birth*. (This photo is for scanning Mobile No.* do not cross sign). Aadhaar No. Email Height ( in cm)*. Visible Identification Mark*. Current Residence Address : House No / Flat No. * Sector / Village*. Tehsil / Sub-District* Chandigarh District* Chandigarh State/UT* Chandigarh Pin Code*. Permanent Residence Address : Same as the current address. House No / Flat No. * Sector / Village*. Tehsil / Sub-District* District*. State/UT* Pin Code*. Self-Undertaking I Son/Daughter of Sh.. aged resident of ., verify that the above contents and supporting documents are correct to the best of my knowledge Photograph of the person and belief and nothing has been concealed therein.

2 I am aware that in case the information furnished applying for the certificate above is found to be incorrect, I shall be liable for prosecution under Section 177 & 191 of the Indian with cross signature Penal Code, which stipulates imprisonment and fine. Date: Signature: .. Place: Name : .. *Without cross signature (half on paper and half on photograph) and signature on undertaking the APPLICATION will be rejected Check List of Requisite Document Required while Applying (Please check against the document being provided while applying). Applicant has to bring original documents for verification and scanning at Sampark 1 APPLICATION form 2 Identity Proof of the applicant 3 Photograph (an additional photograph for pasting on ID card not to be stapled with form ). 4 Residence Proof 5 Date of Birth proof Date: .. Signature : .. Name.

3 Undertaking from Sampark Operator It is hereby certified that the original documents as specified in the above checklist have been personally seen by me and the same have been uploaded in the online APPLICATION Date: .. Signature : .. Name : .. Documentary Proof of Residence Documentary Proof of Identity Documentary Proof of Date of Birth Passport Election Commission Photo ID card Birth certificate issued by a Municipal Telephone (BSNL landline or post-paid mobile Aadhaar card / E-Aadhaar letter issued by Authority or any office authorized to issue bill) on the Name of Applicant government of India. Birth and Death Certificate by the Registrar of Births & Deaths Election Commission Photo ID card Driving License School leaving certificate / Secondary School Applicant's current and valid ration card Passport leaving certificate/ Certificate of Recognized Aadhaar card / E-Aadhaar letter issued by Arm's License with Photo Graph Boards from the school last attended by the government of India.

4 Central Government Health Scheme card or applicant or any other recognized educational Registered Rent Agreement (for a period of Ex-servicemen Contributory Heath Scheme institution more than one year) photo card Passport Photo Passbook of running Bank Account Applicant's current and valid ration card with Affidavit sworn before a magistrate stating the (Scheduled Public Sector Banks and Regional Photograph date of birth in case of illiterate and Semi- Rural Banks only) Photo Identity card issued by the Central literate(Below Class 5). House Allotment Letter Government or a State Government or a Pan card Revenue Record Public Sector Undertaking Age assessment certificate from PMO Sector- Registered Sale Deed Pensioner card having photograph of the 16 or Sector-32 Government Hospital applicants Certified Voter List Certificate of Identity in original signed by Member of Parliament or Member of Legislative Assembly or a Gazetted Officer containing duly attested photograph Bank certificate in original on letter head from the branch (along with name and stamp of the issuing officer) containing duly attested photograph and bank account number of the applicant(Scheduled Public Sector Banks and Regional Rural Banks only).