GOVERNMENT OF GOA,
DIRECTORATE OF ANIMAL HUSBANDRY& VETERINARY SERVICES,
PASHUSAMVARDHAN BHAVAN, PATTO, PANAJI – GOA
APPLICATION FORM FOR BACK-YARD POULTRY UNITS UNDER SPECIAL
COMPONENT PLAN SCHEME
1) Full Name of the applicant: - -------------------------------------------.
(in block letters) Surname First Name -Father’s/Husbands Name
2) Permanent Address (a) House No. ……………………………….
(b) Village Ward……………………………..
(c) Taluka …………………………………….
(d) District ……………………………………
3) Educational Qualification --------------------------------------------------
4) Employed/Unemployed ---------------------------------------------------
5) Age -----------------------------------------
6) Caste --------------------------------------
7) Number breed of existing poultry birds with the applicant, if any
-------------------------------------------------------------------.
8) Annexure to be attached
a) Caste Certificate
9) I hereby certify that if information furnished by me in the application form is true to the best of my knowledge & belief & also agree that in case it is found false
I shall be liable for any action as Government may find it fit and appropriate to impose upon me.
Dated: - Signature of Applicant
(Name)
FOR OFFICE USE ONLY
Recommendation from ---------------------------------------------------
Area Veterinary Officer/Assistant Director ------------------------------
Dated: - Signature Designation
OFFICE SEAL