ANNEXURE "A"
Dated :-
To,
The Mamlatdar of
Panaji Goa
Sub :- Application for the issue of residential certificate
Sir,
I, undersigned request you to issue me a residential certificate as per the given address, I am residing at since birth for the past years and months.
1. Full name of the Applicant :-
2. Age :-
3. Occupation :-
4. Name of the household in which the applicant resides
5. Place of residence :-
6. Name of the father/Husband :-
7. House No :-
8. House is located at i. E. Village/Street,etc :-
9. Name of the Village Panchayat/Muncipal Council :-
10. The period of residence or since the applicant :-
11. The period of residence prior to the place of residence as indicated above in case the applicant was not continuously at the above :-
12. If employed, where employed during the last 6 months :-
13. If business, the place of the business during the last 6 months :-
14. If student, the place of study, during the last 6 months :-
15. Relationship of the applicant with the head of the household in which he/she resides :-

16. whether the applicant’s name is included in the ration card of this taluka and Electoral Roll. In the affirmative indicate the ration card No. and Electoral Roll. No.
17. Whether the applicant has the immovable property or share in it in the place of residence and if so give details :-
18. Whether the applicant is Married/Unmarried :-
19. Purpose for which the residence certificate is required and for whom it is to be produced :-

Signature of the Applicant

Enclose Attested xerox copies of Documentary Evidence :-
Birth Certificate
Educational Certificate such as School Leaving Certificate, Bonafide Certificate.
Ration Card