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 - | .. | ||
| .. | |||
| 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: | |||
