Request Form For Mobile Number Change (To Be Uploaded) : Undertaking

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REQUEST FORM FOR MOBILE NUMBER CHANGE ( TO BE UPLOADED)

To,
Shri/Smt./Miss _______________________(Pass Issuing Authority)
________________________________Office,

Dear, Sir/Madam,
I hereby apply for change of my mobile number for PRCP/Widow Pass to
________________________(new number here)
My/ Pensioner’s service particulars are as follows:-

1. Name of pensioner/family pensioner __________________________________


2. Designation _______________________________________
3. Department _______________________________________
4. P.P.O no. ____________________________________________
5. Date of appointment _________________________________
6. Date of retirement __________________________________
7. Date of death of pensioner (In case of family pensioner)_________________
8. Details of family/dependent members:-

S.No. Name Relation Date of Birth Identification


marks
1
2
3
4
5

9. Address:__________________________________________________________
__________________________________________Pin Code _______________

UNDERTAKING-

I, the undersigned hereby certify that above information is correct as per my


knowledge & any fake/misleading information may lead to suitable disciplinary
action against me.

Your’s Sincerely

Signature/thumb Impression____________

Name of applicant___________________
ࠀȀሀĀल Ȁ⺁ Ȁ ल ल汥  ( लࠀ 汥ሀ ሀ ሀ 묈 )

ሀ ,ꀀ
爠 / 爠 昍爠 / 崸 ሀ⺁� _______________________ ( ሀ ሀ⺁� ⺁ ሀल ሀ ሀ⺁�)
________________________________ ሀ汥ሀल汥,

汥 ࠀ 汥 / ࠀ 汥ሀ,

㔱 昍 ሀ⺁ሀ 爠. ⺁. 爠. 爠/  ሀ ሀ ल ሀ ࠀȀሀĀल Ȁ⺁____________(汥 ሀ⺁ 汥ሀ Ȁ⺁ ሀलꀀ )


ꀀ Ȁ ल ሀ  ⺁昍ሀ I
⺁ / ꀀ ⺁ ሀ ሀ ⺁ Ā ሀ⺁ 묈 : -
1. ꀀ ⺁ / ሀi⺁ሀi⺁ ꀀ ⺁ ሀ ሀ _________________________________________
2. ሀ ____________________________3.  ሀ __________________________
4. 爠. 爠. . Ȁ⺁ ________________________5. iĀ ꀀ 昍 ⺁ ________________
6.   昍 昍 ⺁ _______________________________________________________
7. ꀀ ⺁ ఝ븨 汥崸 昍 ⺁ ( ሀi⺁ሀi⺁ ꀀ ⺁ ሀ ल ꀀ)________________________

8. i⺁ሀ⺁ / 昍 汥 ሀ ⺁ -

. . ሀ Ȁ ␍ 昍ሀ⺁� ሀ ሀ

1.
2.
3.
4.
5.
6.

9. 昍ሀ :___________________________________________________________________________
_______________________________________________________ ࠀ ____________

⺁ :

㔱, ࠀ 昍ሀ ⺁� 汥 ሀ 昍 ⺁昍ሀ ⺁ ⺁ࠀ‵ ሀ ሀ⺁� ⺁ ሀ 崸 ሀ⺁ � 묈 ⺁ 爠 爠 ल昍


/ ሀ ሀ ⺁ ⺁ लሀ 昍 崸 ሀ ሀఝ ሀ汥ሀሀ � ሀ 昍爠 묈

ሀ ⺁

昍ሀ ⺁ / ሀ ሀ __________________

 ሀ ሀ ________________________

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