FORM A

[see section 12(1)] (Application to be filled by a convicted prisoner or an adult member of his family for Parole/Furlough) 1. Number and Name of the prisoner : 2. Father’s Name : 3. Caste : 4. Complete Residential Address : 5. Reasons for release : Emergency Parole/Regular Parole/Furlough/Custody Parole (Signature or thumb impression of the Applicant) DECLARATION BY THE ELIGIBLE CONVICTED PRISONER I hereby declare that I request to be released temporarily (Emergency Parole/Regular Parole/Furlough/Custody Parole) under section 3 or 4 or 5 or 6 of the Haryana Good Conduct Prisoners (Temporary Release) Act, 2022, and on being so released shall faithfully comply with the conditions of my release. (Signature or thumb impression of the Applicant) (To be filled by the Superintendent Jail) Casual/ Hardcore 1. Number, Name and Age of the Prisoner : 2. FIR detail : 3. Full conviction detail alongwith fine : 4. Detail of period actually spent in jail : Year Months Days up to the date of application (from ______ to ________ ) 5. Remission Earned : Year Months Days 6. Unexpired Sentence : Year Months Days 7. Details of other conviction cases, if any : 8. Details of pending cases, if any : 9. Physical and mental condition of the Prisoner : 10. Conduct in jail : (Details of jail offences to be enclosed, if any) 11. (i) Date when temporary release was last granted : (ii) Date when temporary release was last rejected : 12. Whether the Prisoner is eligible for release as per : provisions of the Act 13. Recommendations of Superintendent Jail : 14. Any additional remarks : Entries checked with warrant Dated Superintendent Jail _____ Jail, ______.