Grievance Application Form

Applicant's Personal Details

Applicant's Salutation *

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Applicant's First Name *

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Applicant's Middle Name

Applicant's Last Name *

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Guardian's Salutation *

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Guardian's First Name *

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Guardian's Middle Name

Guardian's Last Name *

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Relation with Guardian *

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Applicant's Economic Status If you select BPL, you have to upload supporting document!

Applicant's Gender

Applicant's Qualification

Applicant's Date of Birth

Applicant's Religion

Applicant's Marital Status

Applicant's Caste

Applicant's Aadhaar Number

Applicant's Photo

Applicant's Address Details

Address Line 1 *

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Address Line 2

Address Line 3

Country

State

District

Postal / Zip Code

Applicant's Contact Details

Mobile Number *

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E-Mail

Service Specific Information

Complainant Category *

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To which District Magistrate(DM) do you want to lodge your grievance with? *

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Have you lodged your grievance to this office on the same subject earlier? *

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Yes

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If Yes, Earlier lodged grievance details

Enter Specific Details about your Grievance *

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Relief/ Claim Sought

Service Output Type *

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Office

Eligibility

1. Do you have any valid identity with photo? *

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Yes

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2. Do you have any Supporting Document related to your Grievance to upload? *

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Yes

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Do you consent to share your email Id and mobile number with Rapid Assessment System developed by Government of India for taking your feedback on the service? *

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Yes

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Note: Please upload filled and signed (scan) copy of "Common Application Form" in Attach Annexure Page.