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Raise Complaint - Online Vigilance & Enforcement Form

Personal Information

Name: *

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Gender: *

Male Female Other

DOB: *

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Age: *

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Address: *

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Pin Code: *

Please enter Pincode Please enter valid Pincode

Phone:

Fax:

Mobile: *

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Email: *

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Licensee Details

District: *

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License Type: *

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License: *

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Brief Description: *

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RECORDING OF A COMPLAINT OR INCIDENT

Particulars of accused persons: *

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Nature of the offence: *

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Source: *

Please select source

Date of Complaint: *

Please enter date of complaint

Place of Occurrence: *

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Name of Plaintiff: *

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Address of Plaintiff: *

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Contact Number of Plaintiff:

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