FORM – A
[ See Rule – 4 (1) ]

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 mater 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 Full Signature of the Applicant
Date 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