| 1.Name of the
Raiyat |
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| 2.Father’s/Husband’s
name |
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| 3.Address |
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| 4.Specific purpose for
which the land Will be utilised after conversion. |
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| 1.Particulars of
land |
: |
| a.Holding Number |
: |
| b.Plot Number |
: |
| c.Area |
: |
| d.Classification and
status as per Current R.O.R. |
: |
| e.Village with Thana
Number |
: |
| f.Others, if any
|
: |
| Whether land is situated
in any area Within one-half Km. on either side of |
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| A National Highway/ One/
fourth Km. |
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| On either side of State
Highways, if so, |
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| The details
thereof. |
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| 1.Whether the land
situated in a Muncipal/N.A.C,/ Developing area/Rural area,If so, the
details thereof. |
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| 1.Date from which the land
is intended To be used/already used for non-Agricultural
purpose. |
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| 1.Source of
ownership |
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| 2.Approximate market value
of the land |
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| Date
: |
Signature of the
applicant |