FORM - A

                                                                              See  Rule  -4(I)

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

To

        The Public  Information  Officer

        ( Name of the office with address )

        1. Full  name of the applicant

        2. Father /  Spouse name

        3.  Permanent address

        4. Particulars in respect of Identity of the applicant

        5. Particulars of information  solicited

            (a)  Subject matter  of information

            (b) The period to which the information relates

            (c) Specific details of information required

            (d) Whether information is required by post or in person

                  ( The actual postal charges shall be included in providing information)

           (e) In case by post ( ordinary , registered or speed )

    6. Address to which information will be sent & in which form

    7. Has the information 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 of the same

Place

Date                                                                        Full Signature of the applicant

                                                                               address

                                Office of the public Information Officer

            Received the application from ____________________________________________

      Address  _____________________________________________________________________

    on   ____________________________________  seeking information .

      Place 

      Date                                                          Full name of Public Information Officer

                                                                      Designation

                                                                      Seal