ORDER
Ordered that the Resolution be published in the Odisha Gazette and copies thereof forwarded to the A.G., Odisha/ all Departments of Govt./all Heads of Departments/all RDCs/all Collectors/all Tourist Officers for information.
By Order of the Governor
G.K. DHAL
Principal Secretary to Government
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ANNEXURE-'A'
Application (in duplicate) for availing benefit under "Baristha Nagarika Tirtha Yatra Yojana"
1. Name of the applicant :
(in Block capital letter) (I.D proof to be enclosed)
2. Father Name/ Husbands name :
3. Permanent Address :
4. Present Address :
5. Contact No. Telephone/Mobile/E-mail :
6. Date of Birth :
7. Age on the date of application :
(Proof to be enclosed)
8. Sex :
9. Category - (APL/BPL) :
(Proof to be enclosed)
10. Name of the attendant if companied with the senior citizen :
(Copy of Id proof, Photograph,
Address, Age, Category should be attached)
11. Relationship of the attendant accompanied with the senior citizen. (A separate application form should also
be submitted simultaneously for the
attendant and the senior citizen)
12.
13.
Photograph one to be affixed in the space & another to be attached
Medically fitness certificate with undertaking that, the pilgrim should be physically & mentally sound to undertake the journey and should not be suffering from any communicable diseases like T.B. difficulty in breathing, Heart diseases etc. (Medical certificate to be attached) Whether the pilgrim is a Income tax payer or not (Annual gross income for last financial year proof to be attached with Pan card)
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14.
UNDERTAKING
I, Sri/Smt.________________________________________Son/Daughter/Wife of ___________________ do here by declare that the above information furnished by me, are true to the best of my knowledge and belief. I will be held responsible for any false information & hiding facts and will be deprived of the benefit under the scheme if detected at any time.
Signature:
Date:
Printed and published by the Director, Printing, Stationery and Publication, Odisha, Cuttack-10 Ex. Gaz. 1618-173+300
Destination to be visited :
(The pilgrim can choose any one of the
destinations for visit out of the
destinations specified by Government in
Resolution No.2583/TSM, dated the 1st
February, 2016)