Note: All fields with * mark are mandatory.

To
The Sub – Divisional Magistrate …………………………………………………………...

Sub: Prayer for Permanent Resident of Tripura Certificate (PRTC)

Sir,
I would like to avail the aforesaid service from your office. Required details are furnished hereunder

1. Applicant’s Personal Details

a Applicant's Salutation * (tick the appropriate) Mr. Mrs. Ms. Er. CA Dr. Prof.

Applicant's First Name * Middle Name Last Name *

b

c Guardian's Salutation * (tick the appropriate) Mr. Mrs. Ms. Er. CA Dr. Prof. Late

Guardian's First Name * Guardian's Middle Name Guardian's Last Name *

d

Wife Spouse Father Mother Son

Relation with Daughter Brother Sister Father-in-Law Mother-in-Law
e Guardian * (tick the Brother-in-Law Sister-in-Law Nephew Niece Grandson
appropriate)
Granddaughter Grandfather Grandmother Daughter-in-Law

Applicant's Date of Applicant's Gender *

f g Male Female Transgender
Birth * (dd/mm/yyyy) (tick the appropriate)

Widow / Christiani
Marital Applicant's ST Hinduism
Widower Applicant's ty
Status * (tick Caste * (tick
h Married i SC j Religion *(tick the Sikhism Islam
the the
Single OBC appropriate) Buddhism Other
appropriate) appropriate)
Divorced Other Jainism

Illiterate Diploma or Equivalent

Literate (without educational level). Graduation or Equivalent
Applicant's Qualification * (tick the Primary Schooling (I - V) Post-Graduation or Equivalent
k
appropriate) Secondary Schooling (VI - VIII) Doctoral or Equivalent
Senior Secondary Schooling (IX - X) Post-Doctoral or Equivalent
Higher Secondary Schooling (XI - XII) Others

Applicant's Economic Status * Applicant's

l APL BPL m
((tick the appropriate)) Aadhaar Number

2. Applicant’s Address Details

District * Sub Division *

Location Type * Block Municipal Corporation Municipality Nagar Panchayat ADC

Name of Block / Municipal Corporation /

Municipality / Nagar Panchayat / ADC

Name of Gram Panchayat / Ward / Village

Council

Name of Habitation / Area Name / House

No

Name of Tehsil Police Station Post Office and Pin code *

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 Note: All fields with * mark are mandatory.

3. Applicant’s Contact Details

a Mobile Number * (10 digits only) b E-Mail

4. Service Specific Information

a Service Output Type * Hard Copy e Copy

5. Provide Guardian’s Declaration for MINOR APPLICANT : Annexure I

6. Provide Attestation Certificate by any Gazetted Officer : Annexure II

7. Eligibility
a Whether Applicant Born in Tripura? * Yes No
b Whether Applicant is residing in Tripura continuously for not less than 10 years? * Yes No
Whether Applicant’s Parent (s) are residing in Tripura continuously for not less than 10
c Yes No
years?*
Whether the Applicant’s Parent (s) are working in Govt. of Tripura, either in deputation
d Yes No
outside the state or in Tripura Bhawans? *
Whether the Applicant’s Parent (s) are working in other State/ Central Govt., or in PSU/
e Yes No
Private organizations outside Tripura/? *
Whether the Applicant’s Parent (s) is holding Citizenship Certificate OR Permanent
f Yes No
Resident Certificate of Tripura? *
g Whether Applicant’s Spouse is a Permanent Resident of Tripura? * Yes No
h Do you want to upload any Other Supporting Document? Yes No

Please provide details for the items you have selected “Yes” –
Document Name Reference No. Date of Issue Issued by
a
b
c
d
e
f
g
h

8. Applicant’s Birth Place details

District * Sub Division *

Location Type * Block Municipal Corporation Municipality Nagar Panchayat ADC

Name of Block / Municipal Corporation / Municipality /

Nagar Panchayat / ADC

Name of Gram Panchayat / Ward / Village Council

Name of Habitation / Area Name / House No

Name of Tehsil Police Station Pin code and Post Office *

9. Declaration
I do hereby declare that all the details furnished above are true to the best of my knowledge and belief.

Date:
Place: Signature / Thumb Impression
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 Note: All fields with * mark are mandatory.

Annexure I: Guardian’s Declaration for MINOR APPLICANT

Annexure II : Attestation Certificate by any Gazetted Officer

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