RTI APPLICATION

Date of Filing: ________________

To,

The Public Information Office,

________________________,

________________________,

________________________.

A. Contact

Details

1. Name of the Applicant : ____________________________

2. a) Mailing Address : ____________________________________________________
b) Tel. No : __________________________________________________________
c) E-mail : __________________________________________________________
3. Whether a citizen of India

Yes

B. Details of information sought

Page 1 of 4

No

1. Nature of information sought

(a) Life & liberty of the person *

(Please Mark)

(b) Other than (a)

2. Type of information required (a) Copy of documents

(b) Inspection of records

Yes

No

Yes

No

Yes

No

Yes

No

(c) Sample of material

(d) Other information

3. (a) Whether information sought relates to third

party?

Yes

No

_____________________

(b) If yes his/her name & address

_____________________
_____________________

Page 2 of 4

4. Specify the particulars of information required

1. __________________________________________________________________
__________________________________________________________________
2. __________________________________________________________________
__________________________________________________________________
3. __________________________________________________________________
__________________________________________________________________
4. __________________________________________________________________
__________________________________________________________________
5. __________________________________________________________________
__________________________________________________________________

5. Time period for which information is required: _________________________

6. Whether applicant belongs to BPL category:

Yes

No

Proof of BPL attached

Yes

No

Page 3 of 4

7. Details of fee paid

Rs.______________

Signature of the applicant

Page 4 of 4