Prasanth Gopalakrishnan 9447302176

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Reverue (p) Departmenr
NOTIFIC4TION
Rurrs
2012
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2. 1
"*
fV"APPeut
[See Rule 1 i (8) and.16 (1)l
Application
Form forAssignment
o{ Land on Regtsiry
I. Narne ofaPPlicant
2. Nalionaliry olthc aPplicant
f . ,lg"
'nO
Date of Birth
4. Name of Wife 'Husband , :
5 Present address
r Dcrmanent address{As
given rn
" ni'i* curo eiection'Card'
Passpofl or UID Card)
': 1:Tfi'j:[:::ff# lJilJi.,
(a) Ration Card numbe
@) Election Card nrimb
(c) UtD Card number
(d) Passport numb€r
8. Phone numbe":'il1i"ll11*,-,
re aPolicarrt al the ttme u
' (a) Mohile Phone
ft) Land Pbone
o Whether the aPplicant belongs to
'
*,:Hil;^;) rIY""'nu'"th'
category
!n hetber thc aPPiicant is an
'u l--tt}t"^"" (Yes'lo) I{Yes'
give details
: the applicant is disabled
active military service ora
ofthose who killed
active military sen ice
). Ifyes, give details
the appJicant belongs to
holders' with annual incdme
r than. ( 25,000
). If yes, give details
the applicant is a recipient
award from Military
of such a person
). If yes, give dehils
and annual family
of the applicant
of assignment
site/cultivationrbenefi
cial
of Iand in possession/
of land owned or occupied
r applicani and/or his fanrilv
cm (iointly o.r severdliyJ
.#
I E{ent (Aq€r'Cent/Sq,
Merre)

3. 4
PART I
lDetails of total land in Possgsslon
Dand in Pqssession'
situated in-
(a) Mllage
O) Tahi(
' G) Distriot
6) SurveyNunbet
"*lJll,"Ilt::", centsi sq m etre)
3. Boundaries ofland in possessiort-
(a) . South
'O) Nonh
(c)'East
(d) West
4. Nature ofland (wet or dr,)
Teriure of land (Re*'.* TT::'
i
JJ,]*"'*",n*o"Putotobf
5er
larr .{f
,n and enjoYment of the
rs a Iandlesq person or u O"r*gd9, o""upying any landj
sDistrist to rvhich priority is
for assignrnent
Districts to which priority is
Fir.st
Second
Third'
Fourth
Fiftl
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