* Filling of all the star marked fields are compulsory
Name in full *

Name of Guardian *

Date of Birth *

Present Address *

Permanent Address *

Contact Number *

E-mail ID *

Details of Family Members * (atleast one entry is required)

SL Name Relation Age Occupation Monthly Income

Education / Professional Qualification *

Marital status * SingleMarriedWidowWidowerSeparatedDivorced

Details of present / last occupation *

Son(s)/Daughter(s)/Nearest Relative(s) who can be contacted in case of emergency *

  • Person to contact SonDaughterNearest Relative
  • Name
  • Address
  • Contact no

Health Condition

  1. Any serious illness? In case of Yes, please specify

  2. Any infection disease? In case of Yes, please specify

  3. Any disability? In case of Yes, please specify

  4. Are you ready to devote time to society? * YesNo

Financial Status (indicate present income) *

Financial Support *

Your Reason(s) for joining the Belashuru Old Age Home *

Any other details

Date *




, son of / wife of / daughter of,

solemnly declare that I have thoroughly read/heard the details conditions/rules/regulations in the context of declaration for Security of Bela Shuru and that I categorically chose to the category of boarder and after reading I solemnly declare that I / my son / daughter / husband / who soever my local guardian will follow all conditions written in the declaration for security deposit.

I Agree