Application Form - Senior Citizen Identity Card (Sampark) (Page 2 of 2) in pdf

Check List of Requisite Document Required while Applying

(Please check against the document being provided while applying)

Applicant has to bring original documents for verification and scanning at Sampark

Application form

Identity Proof of the applicant

Photograph (an additional photograph for pasting on ID card not to be stapled with form)

Residence Proof

Date of Birth proof

Date: ………………………………………..

Signature : ………………………………………………………………..

Name

: ………………………………………………………………..

Undertaking from Sampark Operator

It is hereby certified that the original documents as specified in the above checklist have been personally seen by

me and the same have been uploaded in the online application

Date: ………………………………………..

Signature : ………………………………………………………………..

Name

: ………………………………………………………………..

Documentary Proof of Residence

Documentary Proof of Identity

Documentary Proof of Date of Birth



Passport

Election Commission Photo ID card

Birth certificate issued by a Municipal



Authority or any office authorized to issue

Telephone (BSNL landline or post-paid mobile

Aadhaar Card / E-Aadhaar letter issued by

Birth and Death Certificate by the Registrar of

bill) on the Name of Applicant

government of India.

Births & Deaths



Election Commission Photo ID card

Driving License



School leaving certificate / Secondary School



Applicant's current and valid ration card

Passport

leaving certificate/ Certificate of Recognized



Aadhaar Card / E-Aadhaar letter issued by

Arm’s License with Photo Graph

Boards from the school last attended by the



applicant or any other recognized educational

government of India.

Central Government Health Scheme Card or



institution

Registered Rent Agreement (for a period of

Ex-servicemen Contributory Heath Scheme



Passport

more than one year)

photo card



Photo Passbook of running Bank Account

Applicant's current and valid ration card with

Affidavit sworn before a magistrate stating the

date of birth in case of illiterate and Semi-

(Scheduled Public Sector Banks and Regional

Photograph



literate(Below Class 5)

Rural Banks only)

Photo identity card issued by the Central



Pan Card

House Allotment Letter

Government or a State Government or a



Public Sector Undertaking

Age assessment certificate from PMO Sector-

Revenue Record



16 or Sector-32 Government Hospital

Pensioner Card having photograph of the

Registered Sale Deed

applicants



Certified Voter List



Certificate of identity in original signed by

Member of Parliament or Member of

Legislative Assembly or a Gazetted Officer

containing duly attested photograph



Bank certificate in original on letter head from

the branch (along with name and stamp of the

issuing officer) containing duly attested

photograph and bank account number of the

applicant(Scheduled Public Sector Banks and

Regional Rural Banks only)

Application Form - Senior Citizen Identity Card (Sampark) Page 2

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