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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,