The Mandal Revenue Officer,
1. I.A.B(Existing full name of the personconcerned in Block Letters). Insert his full present address showing Door No Locality, Village or town or Cirty,Police Station, Taluk,& District where born at and as a Citizen.
2. My age on the date of application is(date of birth in the Christian Era and age).
3. My father's full name is/in Block letters.
4. My Mother's full name is/in Block letters:
5. I am single/Married/Widow
6. My wife's/Husband's full name is/was :
7. Marks of identification :
8. Occupation :
9. I am in the service of the State Govt./the Govt. of India. State the nameof the Dept. Designation and date ofhis appointment.
10. Profession or Occupation other thanGovt. service (here state detailsregarding designation, name and addressof Employer, Station of posting etc.)
11. Intend to change my existing name as full name in block letters.
12. I.A.B. to solemnly and sincerely declarethat the fore-going particulars stated in this application are true and I makethis solemn declaration conscientiously believing the same to be true.
Place : Signature of the Applicant
ANNEXURE - II