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FORMAT

UTTAR PRADESH PRAVASI BHARTIYA RATNA PURUSKAR-2020

\tc-i aRT Itn IlTdtzt lAtti&-2020 'i'i *********************************************************

Details About the Applicant

Name

Whether NRI, PIO or OCI .(self attested document to be submitted for proof of status)

(NRI; An Indian citizen who is ordinarily residing outside India and holds an Indian Passport / PIO; A

person who or whose any of ancestors was an Indian national and who is presently holding another

country's citizenship/ nationality i.e. he/she is holding foreign passport! OCI; A person registered as

Overseas Citizen of India (OCI) Cardholder under section 7A of the Citizenship Act,1955)

(i) Father's / Husband's Name

(H) Passport No.

(Hi) Date of Birth —

Native Place in UP

Gender —

Country —

Profession —

Nationality —

Educational Qualification —

Postal Address —

E-mail ID — Mobile No.

4

9r1(

il _ 2.

"Gqi4c-c4 a yedw* ttiiou 4"

Nomination Details

(Please attach self attested proof of Documents)

Fields of Activity —

(As per list/stream mentioned in rule (03) of UP RATNA PURUSKAR notification

no.10/93(NRI)-6-15-03NRI/14 dated 20.01.2015)

Sub- Field —

Career highlights —

Earlier Awards received/-

Significant Contribution of the nominee / Applicant

Achievement

Ira

• - 3 A

Awards / Recognition Received by the Applicant / nominee

State Awards

National Awards

International Awards

Impact of The Work done by The nominee/ Applicant Contribution to the field

Declaration here by declare that all the information &

relevent documents (self attested) submitted by me in this application

form is correct, true and valid.

Signature

Dated

Place

earrAV 3c7. k

11 °I,