CANTEEN SMART CARD APPLICATION FORM
(For Personnel in Police Forces)
(Please read instructions carefully before filling Application Form)
Permanent Employee Number :
Name
(Please leave blank box for space)
Rank & GL No
Scale of Pay
Present Unit
Date of Birth (DD/MM/YYYY)
Date of Joining (DD/MM/YYYY)
Date of Retirement (DD/MM/YYYY)
(In present Rank)
Identification Mark
1. ……………………………………………………………………………………………………………………………………………………………………………………………………….
2. ……………………………………………………………………………………………………………………………………………………………………………………………………….
Gender : Male Female
Marital Status : Married Unmarried Divorcee Widow/ Widower
Spouse Name (Please leave blank box for space)
Identification Mark of Spouse
1. …………………………………………………………………………………………………………………………………………………
Paste your single
Passport Size
Photo in Uniform
without head
gear.
Please Paste.
Don’t Staple.
Paste your Photo with spouse.
(No separate Photos)
Please Paste. Don’t Staple.
Applicant’s Signature
Sign inside the box. Don’t overlap
RECEIPT Application No. ___________
SCPC Thrissur Ph No.04872328757
Received with thanks a sum of Rs.2150/-(Deposit Rs.2000/- + card charge Rs.150/-) from
…………………….......................... …………….PE No. ……………………… for 1 number of Canteen Card
applied
Date : Signature & Stamp of Canteen Authority
Application Number
Present Address
Locality/ Area
Phone Nos.
……………………………………………………………………………………
CERTIFICATE
Certified that all information given above is correct to the best of my knowledge and that I am liable for disciplinary action
including cancellation of Card at any point of time, if the information furnished by me is found wrong.
Station :
Date : Signature of Primary Applicant
COUNTER SIGNED
Certified that applicant is held on strength of this Organization as on this date.
Name of Competent Authority:
Station :
Date : Signature & Stamp of Head of Office
PAYMENT DETAILS
Received with thanks a sum of Rs. ________ from _____________ Personal No. _________ for ______
number of Canteen Cards applied for.
Signature & Stamp of Canteen Authority
INSTRUCTIONS
1. Photograph to be in uniform without headgear
2. All photographs to be attested by countersigning authority
3. Only high resolution photographs with be accepted. Computer (inkjet) printouts/
Photostat photos will not be accepted
4. One Passport size photograph each (single/ Joint) to be affixed at given box.
5. Dependents as per existing definition
6. USE BLOCK LETTERS ONLY. Illegible and incomplete documents can be
rejected and applicant would be responsible for the same.
House No. / Name
Post Office & PIN Code
7. Officer of and above SHO can Countersign the
declaration.
8. Use Black color ink to fill up forms.
9. Smart Card(s) will be issued only to applicant in person
due to security reasons.
District
E-mail ID