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Tamil Nadu Hostels and Homes for Women and Children (Regulation) Rules, 2015

Form IV

[See Rule 4(4)]

Application form for Registration

1. Name of the institution and address ..
Phone number ..
Fax - ..
E-mail ..
2. Place of the institution ..
(i) Registered place ..
(ii) Current place ..
3. Nature of the home ..
[hostel or lodging house or home for women and children] ..
4. Name and address of the contact person ..
5. Details of the governing body ..
(managing committee/executive committee) ..
6. Under which Act the registration is made ..
(i) number, date and place of registration ..
(ii) If renewed, the renewal details ..
7. Total number of girls or boys or women ..
(i) Girls ..
(ii) Boys ..
(iii) Women ..
8. Infrastructure available in the hostel or lodging house or home for women and children ..
9. Details of the manager / resident manager/ care taker's or care giver's / warden (men or women) appointed in the institution. .. ..
(i) Name ..
(ii) Age ..
(iii) Educational qualification ..
(iv) Date of joining ..
(v) Appointed by whom ..
(vi) Salary ..
(vii) Medical certificate ..
(viii) Conduct certificate ..
10. Details of entry and exit points in the institution ..
11. Details of security person appointed in the institution. ..
(i) Name ..
(ii) Age ..
(iii) Educational qualification ..
(iv) Date of joining ..
(v) Salary ..
(vi) Medical certificate ..
(vii) Conduct certificate ..
12. (i) Specify locations where the CCTV cameras have been installed. ..
(ii) If not installed, action taken to install the same ..
13. Details of rooms allocated for manager or resident manager or warden or care taker / care giver or security persons ..
14. Details of registers maintained in the institution ..
15. Details of the visitors room and visiting hours ..
16. The details and phone number of the institution registered in district website. ..
17. The details of the inmates registered in track child website. ..
18. Audit statement details for the past three years done by the chartered accountant. ..
19. Foreign Contribution Regulation Act details. ..
20. Bank account number ..
Bank name and branch ..
I declare that the facts mentioned above is absolutely true to the best of my knowledge
Place: Signature of the Applicant
Date & Seal:




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