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ISSUEANCE OF LOCAL STATUS CERTIFICATE APPLICATION FORM

Applicant Details:-
Applicant Name *:: __________________________
____________________________________
Father’s Name/Husband’s
/Husband’s Name/Guardian’s Name
Name*: _____________________________________________________________
_____________________
Aadhaar No*:_______________________________
___________ Gender*:
Male
Female Community*:
BC
OC
SC
ST
Place of Birth Details:-
Date of Birth*:_________________________
:_________________________ (DD/MM/YYYY) State*:: _________________________________________________
_______________________________________________
District*: ______________________________
__ Mandal
Mandal*: ______________________________ Village *: ________
________________________
Previous Study Details (class IVth to Xth)
Class* School Name* District* Mandal* Village* Year*
IV
V
VI
VII
VIII
IX
X
Education Details:-
Class / Course Studying*:______________________________________
_____________________________________________________________
Institution Name (School/ College/ University)
University)*: _____________________________________________________________________
______________________________
District*: _________________________
___ Mandal
Mandal*: ___________________________ Village *: ___________________
________________________
Locality/Landmark:__________________________________ Pin Code*:________________________________
_
Previous Address Details (in Telangana):
Telangana):-
District*: _________________________
___ Mandal
Mandal*: ___________________________ Village *: ___________________
________________________
Door No: _______________________ Locality/Landmark: ________________________________________ Pin code:
code _____________
Period From* :____________________( dd/MM/
/MM/yyyy) Period To*: __________________________________(
_______( dd/MM/yyyy)
Present Address Details(in
(in Andhra Pradesh):-
District*: _________________________
___ Mandal
Mandal*: ___________________________ Village *: ___________________
________________________
Door No*: _______________________ Locality/Landmark
Locality/Landmark*: ______________________________________
_________ Pin code*:
code ____________
Mobile No*:: ____________________________ Email Id: ______________________________________________________________
_____________________________
Period From* :____________________( dd/MM/yyyy) Period To
To*:: __________________________________( dd/MM/yyyy)
District to which seeks to declare as local candidate*:
candidate*:__________________________________________________________________
_________________________________________________

Informant Details:-
Informant Name*: ________________________
________________________________________ Relationship with the Applicant*:: ________________________
___________________
Email Id: _________________________________________________________
__________________________________________________________ Mobile Number*:: ____________________________
Delivery Type*:
At Kiosk
Post Local
Post Non
Non-Local

Documents List: - (NOTE: All Upload Documents should be in PDF Format only and the size should not exceed 3MB)

Application Form*

Aadhaar Card/Pan Card/Driving
/Driving License/Ration Card/Bank Pass Book/Voter ID Card/Any Other Certificate
Certificate**

Self Declaration Form *

Passport Size Photo * Applicant’s Signature