The Designated Officer snail maintain complete record of the request received and action taken thereof, in electronic database and also in register of the cases of blocking for public access of the information generates transmitted, received, stored or hosted in a computer resource* 16, Requests and complaints to be conf ident ial .— Strict confidentially shall be maintained regarding at] the requests and complaints received and actions taken thereof FORM (See rule 6(2)] A. Complaint t Name of the compla inant : - -_ (Person who has sent the compia*it to the Mntstf v/Department/State Govt /Nodal Officer)
2. Address : _ • City: _ _ _ ^ ^ _ p*n Code:
3, Telephone : , ^ _ _ _ _ _ ftWflX STD code) 4. Fax (rf any) :
5. Mob*c (if any);
S. Email (if any); m B : Details o f websi to/ computer resource/intennediary/ of fending Information hosted on the website (Please give details wherever known)
7. URL / web address : _ _ _ _ 8 IP Address:
g Hvoeriink :
10. ServerVProxy Server address: .
11 Name of the intermediary : ^ ^ _ _ _ ^ ^ _ ^ ^ ^ ^ ^ _ _ _ _ ^ „ 12 URL of the Intermediary (Please attach screenshot/printout of the offending information) 13 Address or location of intermediary in case the intermediary is telecom service provider, network service provider, internet sen/ice provider, web-hosting service provider and cyber caf* or other form of intermediary for which information under points (7}( (6). (91. (10), (11) and (12) are not available*- I qro I I - a n 3(')1. mra m nvm : arowiffl C. Details of Request for blocking
14. Recommendation/Comments of the MinisfY^taie Govt 15: The icw^ at wh**h the comments/ recommendation have been approved (Pleas* specify designation): '__< 16 Hwt the complaint been examined In Mro*stry/St3!e Government: V/N 17 If yes. under which of the following reason* *t fails (please ticK):
(•(Interest of sovereignty or Mtagnty of India
(ii) Defence of India
(iii) Security of (he State {iv> Friendly relations w * foreign Stales (V) Public order
(vl) For preventing incilemerrt to tHe comrrvssion of any cognisable offence relating to above
0. Details of the Nodal Officer forwarding the complaint alongwtth recommendation of the Ministry/State Govt, and related enclosures IS. Name of the Nod
19. Dc vocation
20. organisation:
21. Address City:
22 Telephone:
24 Mob4eI*anyl
25. EmaaCany):
H Officer.
•
6. Any other Information ;
F. Enclosures 1P 2
3.
PtaOote <preflxSTDCOde) 23. Fax (if *ny):
• Date Place Signature (No 9(16W2004-f C] N RAVtSHANKGR.Jt Sety 28££^XM~^