Form 4
Duare Sarkar
Registration No.
Application for Inclusion of left out members of a family already having
Digital Ration Card(s) for both Rural & Urban Areas
(* marked fields are compulsory)
Section A: Details of Head of Family (HoF)/ eldest member having DRC
Name*
Ration Card Type* AAY PHH SPHH RKSY-I RKSY-II
(Tick where applicable)
Ration Card Number*
Section B: Details of new members applying for DRC
(Aadhaar not mandatory for applicants below age of 5 yrs.)
Details of the 1st Applicant
Name of the
Applicant*
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Aadhaar Number*
EPIC Number
Details of the 2ndApplicant
Name of the
Applicant*
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Aadhaar Number*
EPIC Number
Details of the 3rdApplicant
Name of the
Applicant*
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Aadhaar Number*
EPIC Number
Details of the 4thApplicant
Name of the
Applicant*
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Aadhaar Number*
EPIC Number
বি. দ্রঃ সঠিক পবিমাণে রিশন রপণে ও অনয রকউ যাণে আপনাি জনয িিাদ্দ রিশন েু ণে বনণে না পাণি োি
জনয শীঘ্রই.দুয়ারে সেকাে কযারেে মাধ্যরম / আপনাে রেশন ডিলারেে কারে / রিাে টু রিাে
সারভেরে / বাাংলা সহায়ো রকরে অথিা খাদয পডেদশক ে কার্ালরয়
ে e-KYC এে মাধ্যরম আপনাি
পবিিাণিি সকে সদণসযি বিজজটাে রিশন কাণিেি সাণথ আধাি এিং রমািাইে নম্বি আঙ্গু ণেি ছাপ বদণে
সংযুক্ত করুন।
Section C: Contact details of the family:
Primary Mobile Number*
(For communication)
Secondary Mobile Number
Whatsapp Number
Email ID
If you don’t want us to send e-bill and other important messages, tick the box
Section D: Aadhaar Details of all existing DRC holders of the family*
(Form will not accepted if Aadhaar number is not given)
Name of Member 1
(Head of Family)*
Digital Ration Card No.*
Card Category* AAY PHH SPHH RKSY-I RKSY-II
Aadhaar number* (attach copy)
Name of Member 2*
Digital Ration Card No.*
Card Category* AAY PHH SPHH RKSY-I RKSY-II
Aadhaar number* (attach copy)
Name of Member 3*
Digital Ration Card No.*
Card Category* AAY PHH SPHH RKSY-I RKSY-II
Aadhaar number* (attach copy)
Name of Member 4*
Digital Ration Card No.*
Card Category* AAY PHH SPHH RKSY-I RKSY-II
Aadhaar number* (attach copy)
[ ] I agree that all inputs given above are true to the best of my knowledge. I agree that the application may be
rejected, or the Ration Card if issued, may be cancelled if any information furnished here is found to be false. I also
acknowledge that other legal action may be taken against me for furnishing wrong information or hiding any relevant
information, either at the time of application or at later stage.
Date: Signature /LTI of th e applicant
Checklist of Documents to be added:
1.Copy of Digital Ration Card of Head of Family/one existing Card holder
2.Copy of Aadhaar Cards of all members
3.If age of any new member is less than 5, then Aadhaar is not mandatory; in that case copy of birth certificate of
such member is to be submitted
__________________________________________For Office Use____________________________________
Received against Barcode No…………………..
Duare Sarkar Registration No.
Date………………… Signature and seal
