Application form for admission into old age home/orphanage

Trustee
Sri Sadguru Aadhar Foundation
Gottegere Village, Uttarahalli Hobli
Bengaluru - 560083

Latest Photo, With signature across

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Name in capital letters

Father’s/Husband’s name

Date of Birth

Age

Gender

Present Address

House No

Ward No

Village/Town

Tehsil

District

State

Present address is the same as permanent address

Yes

Permanent Address

House No

Ward No

Village/Town

Tehsil

District

State

Aadhaar No

PPP ID

EPIC

Contact Number

Family Details

Sl No.

Name

Age

Relationship

Occupation

Income per month

Educational/Professional Qualification

Single/Married/Widow/Widower/Separated/Divorced

Details of Present/Last Occupation

Name(s) of Son(s)/Daughter(s)/Nearest Relative(s) along with addresses who can be contacted in case of Emergency

Blood Group

Name & contact number of Relative

Identity Mark

Did any member of the applicant's family receive/received any assistance from the Institute of Public Assistance or any other Govt. Department : Yes/No (lf yes, please give the following information)

Sl No.

Name & address of Govt Deptt

Amount received

Date of receipt

Health Conditions

Any serious illness : Yes/No (ln case of yes, please specify with details)

Yes

ln case of yes, please specify with details

Any infectious disease : Yes/No (In case of yes, please specify with details)

Yes

In case of yes, please specify with details

Any other disability : Yes/No (In case of yes, please specify with details)

Yes

In case of yes, please specify with details

Are you ready to devote time for the society

Yes

Financial Status (indicate present income)

Financial Support

Reason (s) for joining the old age home/orphanage

Please specify whether there is any movable/immovable properties in his/her name

Any other information would you like to share

Date

(Signature/Left hand thumb impression duly attested by Gazetted Officer/ Local MLA/ Gram Sarpanch with Contact No

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DECLARATION BY APPLICANT
(to be given at the time of admission)

s/o,w/o,d/o

hereby declare that I have read/heard and understood the rules and regulations and conditions of eligibility for admission in Old Age Home/Orphanage of Institute of Public Assistance for which I seek admission and undertake to abide by them.

I, the applicant fulfill the eligibility criteria and have provided necessary information which on being found incorrect and misleading, my admission shall be liable for cancellation by the authority of the Institute of Public Assistance at any time without any notice to me.

I further certify that above information as given by me is true.

Date

Signature of witness

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Address of witness

Signature/left hand thumb impression of the applicant duly attested by Gazetted Officer/Local MLA/Sarpanch

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Enclosures

Proof of Age/birth

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Health Certificate issued by Govt. hospital

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Document in support of Permanent Address

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Residential Certificate of l5 years issued by Tehsildar

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Income Certificate issued by Competent Authority

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Two copies of recent passport size photograph

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Copy of the Aadhaar Card / PPP ID

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RULES AND REGULATION

He/she shall abide by Instructions issued by the In-charge/ Steward/ Stewardess and any other authority of the Institution, in the interest of the smooth functioning of the Institution.
He/she shall not leave the Institution without recording his/her movement in the register maintained for the purpose and shall obtain the permission of the Incharge for doing so.
He/ she shall be regular and punctual in attending each and every activity including mealtime.
He/she shall not carry in his/her possession or bring in any equipments inside the institution which are capable of causing harm to him/her or the other residents/inmates.
Person(s) whose name (s) is/are recorded in the form shall be allowed to meet the residents/inmates.
In case of misbehavior, he/she will likely be discharged from the Institution.
Neither he/ she should use harsh/ filthy/ abusive language nor fight with/ hit other residents/ inmates/ staff on duty.

Call: +91 96113 39262, 095912 51111

Email: info@srisadguru.in

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