Water Needed forIndividual HouseStreetLocalityCommunityReligious PlaceSchoolCollegeAgricultural LandEmail Address *Contact NumberPresent / Permanent Address0 / 180Distance from the nearest bore well *PurposeDrinking onlyUtilityDrinking and UtilityCultivationAny Government Scheme AvailableYesNoAny idea of depth of the ground water in the areaYesNoQuality of water available in the areaEstimate for the provisionComplete Installation EstimateIs Electricity availableYesNoApplying for ExpenseFullPartSource for Balance ExpenseBank Details with IFS CodeRecommended / Referred byAadhaarChoose FileNo file chosenDelete uploaded fileEstimate CopyChoose FileNo file chosenDelete uploaded filePhotoChoose FileNo file chosenDelete uploaded fileDeclarationI have read the terms and condition mentioned in the form and agree to abide by it. Information provided in the form is true to the best of my knowledge and belief. Ifany information found to be incorrect or false the Trust reserves right to revoke thesanctions.Today DateDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Submit Form
