2 - PDF Free Download

[ ] 1

2017 2,00,000 4 2,34,000

2,34,000 2017 2,00,000 9

SOLEMN DECLARATION AND UNDERTAKING for Reserved Category (Age 70+ applicant) I, Mr./Mrs./Miss S/W/D/o., Indian citizen, do hereby solemnly declare on oath in the name of ALLAH that : 1. I have already attained the age of 70 years as on 14th November, 2017 and my date of birth as per my International Passport is. 2. I am also aware that Qurrah (draw of lots) will be held within the Reserved Category if applications received under the Reserved Category are more than the allotted Quota of the State. Hence, I shall not claim selection in such a situation as a matter of right. 3. I have never proceeded for Haj either through Haj Committee of India or Private Tour Operator or by any other means. Thus, this is my first Haj journey in my entire life-time. If it is detected at any stage that I have already performed Haj, my seat shall be cancelled at any stage and the entire amount deposited shall be forfeited. 4. Mr./Mrs./Miss S/W/D/o., aged years, Indian citizen who is my relative i.e. my Husband / Wife /Brother / Sister / Son / Daughter / Son-in-law / Daughter-inlaw/Grandson / Granddaughter / Nephew / Niece, shall be my companion. 5. I am aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I shall be abide by the decision of HCoI and shall not show any resentment, whatsoever, against the decision of HCoI. Date : Place : Signature / Thumb impression of the applicant. 6. I/We undertake and mutually agree to take care of each other and belongings of each other during entire Haj journey. 7. I/We have read / understood the Guidelines for Haj 1439 (H) 2018 (C.E.), specifically with regard to eligibility (para 4), payments and confirmation (para 14), cancellation (para 15), accommodation and facilities in Kingdom of Saudi Arabia (para 16), flight (para 19), baggage (para 22), refunds (para 26) and undertake to abide by the same. 8. I/We authorize Haj Committee of India to procure Saudi Riyals on our behalf for disbursal / remittance to CGI. 9. I/We understand that Haj Committee of India works without profit motive and does not attract the provisions of Consumer Protection Act, 1985. Further, we understand that the Courts of Greater Mumbai only shall eercise jurisdiction in all matters of dispute. 10. I/We hereby authorize HCoI to send SMS on our Mobile Nos., even if I/We are registered under DND registry. 11. Particulars given by us in HAF, Solemn Declaration and Undertaking are true and correct to the best of our knowledge. I/We do hereby affirm and declare that in case I/We have suppressed material information or given false / incorrect Declaration / Undertaking, HCoI shall forfeit the amount deposited by us and we shall be liable for prosecution. 12. I/We are aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I/We shall be abide by the decision of HCoI and shall not show any resentment, whatsoever, against the decision of HCoI. 13. I am ready to pay etra charges, as levied by the KSA Haj Authorities for endorsement of Haj visa. Date : Place : Signature / Thumb impression of the applicant (Age 70+ pilgrim) Date : Place : Signature / Thumb impression of the co-applicant (companion) 19

SOLEMN DECLARATION AND UNDERTAKING for General Category I, Mr./Mrs./Miss S/W/D/o., Indian citizen, do hereby solemnly declare on oath in the name of ALLAH that : 1. I am aware that as per Government of India's policy a person can perform Haj only "Once in a life time" through Haj Committee of India. 2. I have never performed Haj through Haj Committee of India in the past and hence I am eligible to apply for Haj-2018, as per Guidelines of Haj-2018. I am aware that Repeaters are not eligible for Haj-2018 and if it is detected at any stage that I have already performed Haj through Haj Committee of India, my seat shall be cancelled and the entire amount deposited shall be forfeited. 3. I have read / understood the Guidelines for Haj 1439 (H) 2018 (C.E.), specifically with regard to eligibility (para 4), payments and confirmation (para 14), cancellation (para 15), accommodation and facilities in Kingdom of Saudi Arabia (para 16), flight (para 19), baggage (para 22), refunds (para 26) and undertake to abide by the same. 4. I authorize Haj Committee of India to procure Saudi Riyals on my behalf for disbursal / remittance to CGI. 5. I hereby authorize HCoI to send SMS on my Mobile Number even if I am registered under DND registry. 6. Particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and declare that in case I have suppressed material information or given false / incorrect Declaration / Undertaking, HCoI shall forfeit the amount deposited by me and I shall be liable for prosecution. 7. I am aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I shall be abide by the decision of HCoI and shall not show any resentment, whatsoever, against the decision of HCoI. 8. I am ready to pay etra charges, as levied by the KSA Haj Authorities for endorsement of Haj visa. Date : Place : Signature / Thumb impression of the applicant. 20

SOLEMN DECLARATION AND UNDERTAKING for REPEATERS in case of Mehram / Companion of age 70+ pilgrim I,Mr./Mrs./Miss S/W/D/o., Indian citizen, do hereby solemnly declare on oath in the name of ALLAH that : 1. I am aware that as per Government of India's policy, a person can perform Haj only "Once in a life-time" through Haj Committee of India and that this condition is waived only for Mehram (Male Member) and Companion of age 70+ pilgrims, if no other Mehram / Companion (who has not performed Haj through HCoI) is available and if he/she pays actual airfare as decided by Ministry of Civil Aviation. 2. I hereby declare that I have performed Haj through Haj Committee of India in the past in the year(s). 3. I declare that no other Mehram / Companion (who has not performed Haj through Haj Committee of India earlier) is available to accompany the following co-applicant(s):(1) (2) (3) 4. I am aware that if the concerned lady Pilgrim or 70+ Pilgrim cancel their Pilgrimage, then my seat as Repeater Pilgrim (accompanying the lady members and / or the 70+ Pilgrim/s) shall also be cancelled automatically. 5. I am ready to pay ACTUAL AIR FARE, as decided by the Ministry of Civil Aviation. 6. I have read / understood the Guidelines for Haj 1439 (H) 2018 (C.E.), specifically with regard to eligibility (para 4), payments and confirmation (para 14), cancellation (para 15), accommodation and facilities in Kingdom of Saudi Arabia (para 16), flight (para 19), baggage (para 22), refunds (para 26) and undertake to abide by the same. 7. I authorize Haj Committee of India to procure Saudi Riyals on my behalf for disbursal / remittance to CGI. 8. I hereby authorize HCoI to send SMS on my Mobile Number even if I am registered under DND registry. 9. Particulars given by me in HAF, Solemn Declaration and Undertaking are true and correct to the best of my knowledge. I do hereby affirm and declare that in case I have suppressed material information or given false / incorrect Declaration / Undertaking, HCoI shall forfeit the amount deposited by me and I shall be liable for prosecution. 10. I am aware that HCoI reserves the right to change the Embarkation Point opted by me. In such case, I shall be abide by the decision of HCoI and shall not show any resentment, whatsoever, against the decision of HCoI. 11. I am ready to pay etra charges, as levied by the KSA Haj Authorities for endorsement of Haj visa. Date : Place : Signature / Thumb impression of the applicant. 21

Medical Screening and Fitness Certificate (To be submitted by the selected pilgrims only) To be obtained from a registered Medical Practitioner MBBS / Government Doctor. [The certifying doctors should ensure proper screening of the pilgrims and clearly recommend whether pilgrim is fit to perform haj or not. Providing false information may lead to legal action/matter being reported to Medical Counsel of India against the medical practitioner]. 1. Cover No. :... 2. Name :... 3. Father's/Husband's Name :.... Diabetic (Tick ( ) as applicable) : es No B. Blood Pressure : High Low C. Past Medical History of : Hypertension / DM (Diabetes Mellitus) / IHD (Ischemic Heart Disease) / Stroke (Cerebrovascular accident) / Chronic renal failure / psychiatry diseases : A. Normal It is certified that particulars mentioned above are correct and the applicant is fit to undertake Haj journey. Name of the Doctor... Registration No.... Seal Signature / Thumb Impression of Applicant Verified by Registered Medical Practitioner (with complete address, Seal & Signature) 23

CANCELLATION REQUEST FORM The Chief Eecutive Officer Haj Committee of India, Haj House, 7-A, M.R.A. Marg (Palton Road), Mumbai - 400 001. HAJ-2018 COVER NO. Sir, It is requested to cancel the pilgrim's listed below and grant admissible refund amount. DETAILS OF PILGRIM (S) TO BE CANCELLED SR. NO. NAME OF THE CANCELLED PILGRIM (s) PASSPORT NO. 1. A 2. 3. 4. B C REASON OF CANCELLATION Please tick ( ) any one ENCLOSURES Please tick ( ) DEATH MEDICAL FINANCIAL Claim Letter Copy of Pay in Slip Medical / Death Certificate DOMESTIC OTHERS Any Other (Please Specify) In case of Death, details of Nominee as per Haj Application Form Name D Relation BANK DETAILS OF NOMINEE (attach copy) Name of the Account Holder Bank Name Branch Name Branch Code Account No. IFSC Code I / We certify that the particulars given above are true and correct. Date : Place: Signature (s) It is certified that the particulars mentioned above are correct and as per entries in the Haj Application Form (s). It is recommended that the Haj application of above referred pilgrim(s) may therefore be cancelled. Date : Eecutive Officer State / UT Haj Committee Place: Forward to: - Haj Committee of India, Haj House, 7-A, M.R.A. Marg, Mumbai- 400 001. Fa No. (022) 22620920 / 22630461 24

LIST OF THE EXECUTIVE OFFICER, STATE / UT HAJ COMMITTEES Sr.No. Name of the State/UT 1. ANDAMAN & NICOBAR ISLAND ADDRESS The Statistical Officer & Eecutive Officer, A & N State Haj Committee Island, Dte. of Social Welfare Building, 2 nd Floor (R. No.309 & 310) Goalghar Junction, (P. B. No.148 H.P.O), Port Blair - 744 101. The Eecutive Officer, Andhra Pradesh State Haj Committee, 3rd Floor, Door No. 39-3-2, Mosque Street, Labbipet, Behind Anjaneya Jewellers, M.G.Road, Vijayawada - 520 010 Andhra Pradesh. Tel No. / Fa No./email Tel : 03192-233051 Fa : 03192-230781 anhaj.committee@gmail.com 2. ANDHRA PRADESH 3 ASSAM The Eecutive Officer, Assam State Haj Committee, Secretariat Comple, (Backside Treasury Office Dispur) F Block, Room No. 3, Post : Assam, Sachivalaya, Dispur, Guwahati - 781 006, Assam. Telefa : 0361-2237296 shcassam@yahoo.in 4 BIHAR The Eecutive Officer, Bihar State Haj Committee, Haj Bhavan, 34, Harding Road (Ali Imam Path), Patna - 800 001, Bihar. Tel : 0612-2203315 / 2217072 Telefa : 0612-2201665 biharstatehajcommittee@gmail.com 5 CHANDIGARH The Sub-Divisional Magistrate - Cum Co-ordinator, State/UT Haj Committee U.T. Chandigarh, Room No. 23, 1st Floor, Estate Office Building, Sector -17, Chandigarh - 160 001. Tel : 0172-2700053 Fa : 0172-2704548 6 CHHATTISGARH Telefa : 0771-4266646 Fa : 0771-4049289 hajcom.cg@gov.in cghajcommittee@gmail.com 7 DADRA AND NAGAR HAVELI The Eecutive Officer, Chhattisgarh State Haj Committee, Near A.K. Memorial High School, Mukharjee Bada, Baeran Bazar,Chhattisgargh - 492 001. The Member Secretary / Resident Deputy Collector, Dadra & Nagar Haveli State Haj Committee, Collector Office, Silvasa 396 230, Dadra and Nagar Haveli. 8 DAMAN & DIU 9 DELHI The Deputy Collector and Eecutive Officer, Daman & Diu State Haj Committee, Administration of Daman & Diu, Office of the Collector, Daman - 396 220. The Eecutive Officer, Delhi State Haj Committee, Haj Manzil, Turkman Gate, Asaf Ali Road, New Delhi - 110 002. Tel / Fa : 0866-2471786 Toll Free No. : 18004257873 apstatehajcommittee@yahoo.co.in aphajcommittee@gmail.com Tel : 0260-2642787 / 2642106 Fa : 0260-2642340 Tel : 0260-2230922 / 2230698 Fa : 0260-2230049 Tel : 011-23230507 Fa : 011-23234041 delhistatehajcommittee@gmail.com 10 GOA The Eecutive Officer, Goa State Haj Committee & Under Tele. Fa : 0832-2772444 / 2772844 Secretary(Home), Government of Goa, Aman Comple, Opp. Santos Engineering Works, Aquem, Maegaon - 403 601, Goa. The Eecutive Officer, Gujarat State Haj Committee, Tel : 079-23250987 / 23277182 23254265 / 22180410 Block No.08, 8th Floor, Sachivalaya, Gandhinagar - 382 010, Gujarat. hajcommitteegujarat@yahoo.com 11 GUJARAT 12 HARANA The Eecutive Officer, Harayana State Haj Committee, & Secretary to Government of Haryana, Home -II Department, Room No. 50 -B, 6th Floor, Harayana Civil Secretariat, Chandigarh - 160 001, Haryana. Tel : 0172-2740229 Fa : 0172-2740526 haryanahaj@gmail.com haryana.state@yahoo.in 13 HIMACHAL PRADESH Tel : 0177-2626450 / 2621907 Fa : 0177-2621154 14 JAMMU & KASHMIR 15 JHARKHAND The Deputy Secretary (Home) & Eecutive Officer, Himachal Pradesh State Haj Committee, Home "C" Department, 4th Floor, Room No. 405, Armsadale Building, Secretariat, Shimla - 171 002, Himachal Pradesh. The Eecutive Officer, Jammu & Kashmir State Haj Committee, J&K Baitul Hujjaj (Haj House), Bemina, Srinagar- 190 017, Jammu & Kashmir. The Eecutive Officer, Jharkhand State Haj Committee, Audrey House, Kankee Road, Ranchi - 834 004, Jharkhand. 25 Tel : 0194-2495365 Fa : 0194-2495367 jkstatehaj@gmail.com Tel : 0651-2283100 Fa : 0651-2400890 jharkhandstatehajcommittee@yahoo.co.in

16 KARNATAKA 17 KERALA The District Collector & Eecutive Officer, Kerala State Haj Committee, Haj House, Calicut Airport, P.O. Mallapuram - 673 647, Kerala. 18 LAKSHADWEEP The Eecutive Officer, Union Territory Lakshdweep, Indira Gandhi Road, Kavaratti 682 555, Lakshadweep 19 MADHA PRADESH The Eecutive Officer, Madhya Pradesh State Haj Committee, Gram Singerholi, Behind Gulmohar Garden, Airport Road, Bhopal - 462 036, Madhya Pradesh 20 MAHARASHTRA 21 MANIPUR 22 ODISHA 23 PUDUCHERR 24 25 26 PUNJAB RAJASTHAN TAMIL NADU The Eecutive Officer, Haj Bhavan, Sy. No.57/17, Thirumanehalli, Net to KNS College, R.K. Hegde Nagar Kogilu Road, Bengaluru - 560 064, Karnataka. Tel : 080-28567673 Fa : 080-28567681 info@karhaj.in Tel : 0483-2710717 / 2717571 Fa: 0483-2717572 keralahajcommittee@gmail.com Haj Committee of Tel : 04896-262321 Kavaratti Island, Fa : 04896-262368 lacajjjj@gmail.com Tel : 0755-2530139 Fa : 0755-2538039 mpshcbhopal@yahoo.in The Eecutive Officer, Maharashtra State Haj Committee, Saboo Siddique Musafirkhana, Ground Floor, Room No.6 & 7, Lokmanya Tilak Marg, Mumbai - 400 001, Maharashtra The Eecutive Officer, Manipur State Haj Committee, Old Guwahati High Court Comple, North A.O.C., Imphal - 795 001, Manipur. The Eecutive Officer, Odisha State Haj Committee, Old Secretariat, Cuttack - 753001, Odisha. Tel : 022-22626786 Fa : 022-22678679 mshc@indiatimes. com maharashtrashc@gmail.com Telefa: 0385-2454586 /2461063 manipurstatehajcommittee.@gmailcom The Eecutive Officer, Puducherry State Haj Committee, No. 1, anam Venkatachalapillai Street, Puducherry - 605 001. Tel : 0413-2233254 / 2343268 The Principal Secretary (Home), Govt. of Punjab & Eecutive Officer, Punjab State Haj Committee, Room no.9, 7th Floor, Sector 21, Punjab Civil Secretariat, Chandigarh - 160 001, Punjab. Deputy Secretary (Home) Cum - Eecutive Officer, Rajasthan State Haj Committee, Home (GR-III) Department (Government Secretariat), Jaipur - 302 005, Rajasthan. The Eecutive Officer, Tamil Nadu State Haj Committee, 3rd Floor, Rosy Tower, No. 13 (Old No.7), Mahathma Gandhi Road, (Nungambakkam High Road), Chennai - 600 034, Tamil Nadu. The Eecutive Officer, Tripura State Haj Committee, Secretariat Comple, Agartala - 799 001, Tripura. Fa : 0671-2306038 / 2301185 Fa : 0413-2222344 pondicherrystate@yahoo.in Tel : 0172-2748519 pbshc@yahoo.co.in Tel : 0141-2227016 Telefa : 0141-2227016 rajasthanstatehajcommittee@gmail.com Tel : 044-28252519 Fa : 044-28276980 tnhajj786@vsnl.com tnshc.chennai@gmail.com 27 TRIPURA 28 TELANGANA 29 UTTAR PRADESH The Eecutive Officer, Uttar Pradesh State Haj Committee,10 -A, Vidhan Bhavan Marg, Lucknow - 226 001, Uttar Pradesh Tel : 0522-2620980 Tel/ Fa : 0522-2622458 shcuplko@rediffmail.com 30 UTTARAKHAND The Eecutive Officer, Uttarakhand State Haj Committee, Haj House, Piran Kaliyar, Roorkee, Haridwar - 247 667, Uttarakhand. Tel/ Fa : 01332-297520 ukshcommittee@yahoo.com 31 WEST BENGAL The Eecutive Officer, West Bengal Haj Committee, Tel : 033-22903617 26 - B, Dilkhusha Street, Haj House (Baitul Hujjaj), Fa : 033-22870274 / 22903617 Kolkata - 700 017, West Bengal. wbshc2011@gmail.com The Eecutive Officer, Telangana State Haj Committee, A.P. Haj House, Razzak Manzli, Public Garden Road, Nampally, Hyderabad-500 001, Telangana 26 Tel 0381-2325841 Fa : 0381-2327583 Tel : 040-23298793 Fa : 040-23236310 telanganastatehajcommittee@gmail.com

HAJ APPLICATION FORM FOR HAJ - 1439 (H) - 2018 (CE) 1. CATEGOR: (Tick ( ) as appropriate) (I) Reserved (Age 70+) PHOTOGRAPH Paste your recent passport size colour photograph having WHITE BACKGROUND (Size:3.5cm 3.5 cm) (III) Ladies without Mehram (II) General (I). If Reserved (Age 70+) give details of companions: Name Relationship 2. Embarkation: (Please read information on Page No. 13 &14 ) (a) Give Name of Embarkation Point you want to travel from (b) Fare of Embarkation Point [see Haj-2017 Airfare on 13 &14] )c) I agree to opt for (a) and pay Airfare approimately as (b) Signature 3. ACCOMMODATION CATEGOR OPTED (Tick ( ) the desired) AZIZIA GREEN 4. NAME OF COVER HEAD (Male adult only) (As per International Passport) 5. APPLICANT S DETAILS Passport Number Date of Issue Place of Issue D D M M Date of Epiry D D M M Gender: Male Female Surname Given Name Father's Name Mother's Name Spouse s Name Date of Birth D D M M Place of Birth Marital Status: Married Unmarried Qualification: Aadhaar Card/Enrolement No.: 6. PRESENT RESIDENTIAL ADDRESS: Blood Group: Occupation: Pin Code District State Mobile Number 0 7. DETAILS OF NOMINEE OF APPLICANT: Name Email ID : Father s / Husband s Name Relationship Address Telephone / Mobile No. Signature / Thumb Impression of Nominee Pin Code District State 8. NAME OF MEHRAM WITH RELATION (for female pilgrims only) Name Relationship Signature / Thumb Impression of Mehram Passport Number 9. Are you a permissible Repeater (Mehram / Companion of Age 70+ applicant) : 10. COVER HEAD S BANK ACCOUNT DETAILS : Bank Name Branch Name Branch Code es Account No. 11. Do you want to perform ADAHI (Qurbani) through IDB : No IFSC Code es 12. Language opted for Haj Guide (Tick ( ) any one): English Hindi Urdu Tamil Kannada Telugu Bengali Gujarati Manipuri 14. Opting JOHFA Meeqat (only for Shia pilgrims): es 13. Are you NRI : es No No Assamese Malayalam No I certify that the information furnished above is true and correct. SIGNATURE / THUMB IMPRESSION OF THE APPLICANT (FOR OFFICE USE ONL) DATE OF RECEIPT SERIAL NO. COVER NUMBER SEATS ADULT EMBARKATION POINT INFANT SERIAL NUMBER OF HCoI All entries in the above HAF have been checked and found in order. Certified that the applicant is eligible to register for Haj-1439 (H) - 2018 (CE). HAF checked by: Data entry by: Eecutive Officer, State / UT Haj Committee

GENERAL INSTRUCTIONS FOR FILLING HAJ APPLICATION FORM (HAF) A) B) C) D) Before filling the HAF, read the Guidelines for Haj-2018. HAF should be filled in ENGLISH BLOCK LETTERS only. HAFs for Haj-2018 can be submitted from 15.11.2017 till 07.12.2017. Column-wise instructions: Column 1 : Tick the applicable category. Reserved Category refers to applicants of age 70+ with one companion. All other applicants are covered in General category. Reserved category applicants have to give additional information regarding companion. Column 2 : Embarkation Point : The pilgrims are free to choose any one Embarkation Point out of the two specified in column no.3 and 4 in the table at page No.13 & 14 against their district and has to pay Airfare accordingly. Fares given on the page 13 & 14 are fare of Haj - 2017 for guidelines only. Actual airfare of 2018 will be decided by tender process which will be different. Column 3 : Tick the desired accommodation category. Details in para 16 of Guidelines. Note that for Haj-2017, the Haj amount payable for Green category was Rs.2,34,000 (appro) and for Aziziya it was Rs.2,00,000 (appro) Column 4 : Enter name of Cover Head who has to be an adult male. He shall be responsible for all communications / payments / refunds. All members of a Cover must be close family members. Column 5 : Fill applicant's details as per passport. Qualification should be one of the following: Aalim / Mufti, Graduate, Matriculation (SSC), Post Graduate, Primary, Under Graduate (HSC) Occupation should be one of the following: Business, Cultivation Doctor, Government Service, House Wife, Professional, Private Service, Retired, Student, Others. Column 6 : Fill complete and correct postal address / mobile number / e-mail id. Column 7 : Fill complete details of nominee of the applicant. Column 8 : Fill details of Mehram, in case of lady pilgrims only. Column 9 : If applicant is a permissible Repeater (refer para 2 of Guidelines) tick es, otherwise No. Column 10 : Fill details of bank account of Cover Head. Column 11 : If all applicants of the Cover want to perform Adahi (Qurbani) through IDB, tick es, Column 12 Column 13 Column 14 E) : : : otherwise No. Tick mark only ONE language for Haj Guide. If applicant is an NRI, tick es, otherwise No. If applicant is a Shia pilgrim opting for Johfa as Meeqat, tick es, otherwise No. Submit complete HAF to State / UT Haj Committee concerned, with following enclosures, as applicable. i) Original International Passport / Self attested photocopy of valid International Passport (as applicable) ii) Proof of address : If address is same as in the Passport no additional document is required. Otherwise a Photocopy of any one of the following is to be attached.ration Card, Driving License, Electricity Bill, Telephone Bill, Water Bill, Gas connection, Election Commission Photo ID card, Income Ta Assessment order, Employee's Identity Card, Aadhar Card, iii) Original Bank pay-in-slip, iv) Copy of cancelled cheque / bank passbook, v) Solemn Declaration (as applicable).

HAJ APPLICATION FORM FOR HAJ - 1437 (H) - 2016 (CE) 1. CATEGOR: (Tick ( ) as appropriate) (i) Reserved-A (Age 70+) (ii) Reserved-B (Fourth Timer PHOTOGRAPH Paste your recent passport size colour photograph having WHITE BACKGROUND (Size:3.5cm 3.5 cm) ) (iii) General / Fifth Timer (i). If Reserved- A (Age 70+) give details of companion: Name Relationship (ii). If Reserved- B, give Cover Numbers and Passport Numbers as under: a) Fourth Timer b) Fifth Timer Passport No. ear ear Cover No. Cover No. 2013 2012 2014 2013 2015 2014 2015 Passport No. 2. ACCOMMODATION CATEGOR OPTED (Tick ( ) the desired) AZIZIA GREEN 3. NAME OF COVER HEAD (Male adult only) (As per International Passport) 4. APPLICANT S DETAILS Passport Number Date of Issue Place of Issue D D M M Date of Epiry D D M M Gender: Male Female Surname Given Name Father's Name Mother's Name Spouse s Name Date of Birth D D M M Place of Birth Marital Status: Married Unmarried Qualification: 5. PRESENT RESIDENTIAL ADDRESS: Blood Group: Occupation: Pin Code District State Mobile Number 0 6. DETAILS OF NOMINEE OF APPLICANT: Name Email ID : Father s / Husband s Name Relationship Address Telephone / Mobile No. Signature / Thumb Impression of Nominee Pin Code District State 7. NAME OF MEHRAM WITH RELATION (for female pilgrims only) Name Relationship Passport Number 8. COVER HEAD S BANK ACCOUNT DETAILS : Bank Name Branch Name Branch Code Signature / Thumb Impression of Mehram Account No. IFSC Code 9. Language opted for Haj Guide (Tick ( ) any one): English Hindi Urdu Tamil Kannada Telugu Bengali Gujarati Manipuri 11. Opting JOHFA Meeqat (only for Shia pilgrims): es 10. Are you NRI : es No 12. Are you a permissible Repeater (Mehram / Companion of Age 70+ applicant) : es 13. Do you want to perform ADAHI (Qurbani) through IDB : es Assamese Malayalam No No No I certify that the information furnished above is true and correct. SIGNATURE / THUMB IMPRESSION OF THE APPLICANT (FOR OFFICE USE ONL) DATE OF RECEIPT SERIAL NO. COVER NUMBER SEATS ADULT EMBARKATION POINT INFANT SERIAL NUMBER OF HCoI All entries in the above HAF have been checked and found in order. Certified that the applicant is eligible to register for Haj-1437 (H) - 2016 (CE). HAF checked by: Data entry by: Eecutive Officer, State / UT Haj Committee

(PA-IN-SLIP to deposit Rs.300/- per pilgrim and maimum of Rs.1,200/- only) Branch : Code : State Bank of India BANK COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NUMBER : 35398104789 HAJ PILGRIM PROCESSING FEE PASSPORT NUMBER OF COVER HEAD Name of Cover Head Date of Deposit : PARTICULARS OF THE PAMENT : Sr. No. NAME OF THE PILGRIM Mobile Number ADDRESS OF COVER HEAD CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. Transaction ID (Bank journal No.) Branch Stamp with Signature Deposited by Bait-ul-Hujjaj (Haj House), 7-A, M.R.A. Marg (Palton Road), Mumbai - 400 001. Branch : Code : HCol COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NUMBER : 35398104789 HAJ PILGRIM PROCESSING FEE PASSPORT NUMBER OF COVER HEAD Name of Cover Head Date of Deposit : PARTICULARS OF THE PAMENT : Sr. No. NAME OF THE PILGRIM Mobile Number ADDRESS OF COVER HEAD CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. Transaction ID (Bank journal No.) Branch Stamp with Signature Branch : Deposited by Code : HAJ 1439 (H) - 2018 (CE) PILGRIM COP COLLECTION - DETAILS ACCOUNT NUMBER : 35398104789 HAJ PILGRIM PROCESSING FEE PASSPORT NUMBER OF COVER HEAD Name of Cover Head Date of Deposit : PARTICULARS OF THE PAMENT : Sr. No. NAME OF THE PILGRIM Mobile Number ADDRESS OF COVER HEAD Amount (In words) Rupees CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Total Rs. Transaction ID (Bank journal No.) Deposited by Branch Stamp with Signature NOTE- photo copy of pay-in-slip may also be used for deposit of amount. If any difficulty, please contact SBI, Mumbai Main Branch. (Mob. No. 09930766530, Tel. No. 022-2262 3971)

(PA-IN-SLIP to deposit Rs.300/- per pilgrim and maimum of Rs.1,200/- only) Branch : Code : Union Bank of India BANK COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NUMBER : 318702010406010 HAJ PILGRIM PROCESSING FEE PASSPORT NUMBER OF COVER HEAD Name of Cover Head Date of Deposit : PARTICULARS OF THE PAMENT : Sr. No. NAME OF THE PILGRIM Mobile Number ADDRESS OF COVER HEAD CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. Transaction ID (Bank journal No.) Branch Stamp with Signature Deposited by Bait-ul-Hujjaj (Haj House), 7-A, M.R.A. Marg (Palton Road), Mumbai - 400 001. Branch : Code : HCol COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NUMBER : 318702010406010 HAJ PILGRIM PROCESSING FEE PASSPORT NUMBER OF COVER HEAD Name of Cover Head Date of Deposit : PARTICULARS OF THE PAMENT : Sr. No. NAME OF THE PILGRIM Mobile Number ADDRESS OF COVER HEAD CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. Transaction ID (Bank journal No.) Branch Stamp with Signature Branch : Deposited by Code : HAJ 1439 (H) - 2018 (CE) PILGRIM COP COLLECTION - DETAILS ACCOUNT NUMBER : 318702010406010 HAJ PILGRIM PROCESSING FEE PASSPORT NUMBER OF COVER HEAD Name of Cover Head Date of Deposit : PARTICULARS OF THE PAMENT : Sr. No. NAME OF THE PILGRIM Mobile Number ADDRESS OF COVER HEAD Amount (In words) Rupees CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Total Rs. Transaction ID (Bank journal No.) Branch Stamp with Signature Deposited by NOTE- photo copy of pay-in-slip may also be used for deposit of amount. If any difficulty, please contact SBI, Mumbai Main Branch. (Mob. No. 09930766530, Tel. No. 022-2262 3971)

State Bank of India (PA-IN-SLIP to deposit Advance / Balance Haj Amount) CASH OR TRANSFER ONL Branch : Code: BANK COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NO.32175020010 Fee Type 25 BANK REFERENCE NUMBER AMOUNT OF : Advance Haj Amount / Balance Haj Amount Date of Deposit : HAJ COVER NUMBER : Mobile Number Name of Cover Head : PARTICULARS OF THE PAMENT SR. NO. NAME OF THE PILGRIM - - 2018 CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. ADDRESS OF COVER HEAD Transaction ID (Bank journal No.) Branch Stamp with Signature Deposited by Bait-ul-Hujjaj (Haj House), 7-A, M.R.A. Marg (Palton Road), Mumbai - 400 001 CASH OR TRANSFER ONL Branch : Code: HCol COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NO.32175020010 Fee Type 25 BANK REFERENCE NUMBER AMOUNT OF : Advance Haj Amount / Balance Haj Amount Date of Deposit : HAJ COVER NUMBER : Mobile Number - - 2018 Name of Cover Head : PARTICULARS OF THE PAMENT SR. NO. NAME OF THE PILGRIM CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. ADDRESS OF COVER HEAD Transaction ID (Bank journal No.) Branch Stamp with Signature CASH OR TRANSFER ONL Branch : Deposited by Code: PILGRIM COP HAJ 1439 (H) - 2018 (CE) COLLECTION - DETAILS ACCOUNT NO.32175020010 Fee Type 25 BANK REFERENCE NUMBER AMOUNT OF : Advance Haj Amount / Balance Haj Amount Date of Deposit : HAJ COVER NUMBER : Mobile Number Name of Cover Head : PARTICULARS OF THE PAMENT SR. NO. NAME OF THE PILGRIM - - 2018 CASH NOTE AMOUNT IN RS. 2000 500 200 100 50 20 10 5 Amount (In words) Rupees Total Rs. ADDRESS OF COVER HEAD Transaction ID (Bank journal No.) Branch Stamp with Signature Deposited by NOTE- photo copy of pay-in-slip may also be used for deposit of amount. If any difficulty, please contact SBI, Mumbai Main Branch. (Mob. No. 09930766530, Tel. No. 022-2262 3971)