Old Form No.

*:
Old Prov. Regn. No.*:

HOUSING

BOARD

HARYANA

Flat No.:

C - 1 5 , A W AS B H A W A N , S E C T
TO
O R - 6 , P A NCH K U L A

Bahadurgarh/Sirsa/Narnaul/Bawal Flats
Last date for deposit of the form in the
Concerned bank on or before 0
01.05.2015.

Applicants Name __________________________________________

1.
2.

a)

Fathers /Husbands Name ___________________________

b)

Mothers Name _______________________________________

Affix Recent
Passport Size
Photograph

Correspondence Address ___________________________________

____________________________________________________________
____________________________
________________________________________________________
_________________________________
Phone No./Mobile
/Mobile No. _______________________________________
______________

3.

Date of Birth _______________________________________________

4.

Sex:
5.

Male

Female

Whether owns any house

house/flat/apartment/Plot either in own name or
in the name of spouse or any dependent relative including unmarried
minor children at Bahadurgarh/Sirsa/
Bahadurgarh/Sirsa/Narnaul/Bawal.

YES

NO

6.

Whether you are a rresident of Haryana State

YES

NO

7.

Category under which reservation claimed

8.

Details of amount deposited:

a)
Amount (in figures) Rs. ________________________________________

YES

NO

(in words)________________________________________
b)

Mode of payment: Bank draft. _____________________

Cash _______________________

9.

10.

11.

Details of Bank Account of applicant:

a)

Bank & Branch Name _______________________________________

b)

Account No. ________________________________________________

a)

Whether earnest money has been got financed from the Bank

b)

If yes, name of the Bank/Branch ______________________________

Name of the Bank & Branch where application deposited ..

Undertaking:
It is certified that I have carefully gone through & understood the terms & conditions of the scheme
schemes
& public notice do hereby undertake to abide by the same. The above information given in the applicat
application is
true & correct to the best
st of my knowledge & belief & nothing has been concealed therein. I fulfill the
eligibility conditions as laid down in the scheme.
I understand
stand that my name is being considered for registration & allotment (if successful in draw of
lots) without verifying my eligibility by the Board. I understand that in case I am found ineligible at any time,
my registration/allotment shall be cancelled wit
without
hout notice & the amount deposited shall be forfeited as per
terms & conditions given in the brochure.
Name & seal of the Bank/Branch ________________________
Signature of the applicant
Name ________________________
Date _________________________

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HOUSING

BOARD

HARYANA

C - 1 5 , A W AS B H A W A N , S E C T
TO
O R - 6 , P A NCH K U L A

Old Form No.* ________________

Old Prov. Regn. No.* ____________________
__
((*To be filled by the Bank from the data
provided to them in the form of CD)
CD

Receipt
Received
S/o,W/o,

application

D/o

from

Sh./Smt./Km.

__________________________________________

____________________________________

Bahadurgarh/Sirsa/Narnaul/Bawal
_____________________

vide

flat,

Bank

alongwith

Draft/Cheque

for

the

registration
No.

registration
amount

of

_______________________

_______________/cash.

Date: ________________

Signature & Seal of Bank

Place: _______________

Registration Period:
Bahadurgarh
Sirsa
Narnaul
Bawal

02.03.2010
02.03.2010
04.10.2010
19.02.2010

to
to
to
to

12.04.2010
12.04.2010
04.11.2010
19.03.2010

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of
Rs.
dated