Submit your First Appeal: ORISSA INFORMATION COMMISSION


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FORM-D
[See Rule 7(1)]
Form of Memorandum of Appeal to the First Appellate Authority under Section 19 (1) of the Act

From
*
*
	(Applicant's Name and address)

Before
	The First Appellate Authority

*1.

Full Name of the Appellant :

*2.

Address :

*	(a)	State :
*	(b)	District :

(c)

City/Town/Village :

(d)

E-Mail ID :

*3.

Paticulars of Public Information officer :

*4.

Date of Receipt of the order appealed against

(Attach soft copy) :

(.pdf,.jpg,.gif file only)

*5.

Last date for filing the appeal :

Paticulars of Information

(a)

Nature of the subject matter of the information required

(b)

Name of the Department to which the
information relates

Name of the Office to which the
information relates

The grounds for appeal

(Details, if any, to be enclosed as soft copy)

(.pdf,.jpg,.gif file only)

Signature of Applicant

(.jpg,.gif,.png,.bmp file only)

VERIFICATION
I,	(Name of the appellant) of
hereby declare that paticulars furnished in the appeal are to the best of my Knowledge and belief, true and correct and that I have not suppressed any material fact.

NOTE :- (*) marked fields are mandatory.Please upload images maximum size (250*50) and document upto (1 MB).