WEST BENGAL COMMISSION FOR PROTECTION OF CHILD RIGHTS

A. Complainant Details:
Name* :
Relationship with the victim* : Parent Relative Friend NGO Self Others
Gender* : Male Female Others
Address* :
Police Station* :
State* :
District* :
Pin* :
Mobile* :
Land Line :
Email :
 
B. Victim Details:
Number of Victim/Victims* :
C. Alleged violator details
Name* :
Gender* : Male Female Others
Address :
Police Station :
State :
District :
Pin :
Mobile :
 
D. Incident Details*
Date of Incident* :
Time of Incident* :
Place of Incident
(with Village/Ward/
Block/District details)*
:
 
E. FIR Details(if lodged):*
with copy of FIR
(upload FIR scaned copy)*
:
Details of Incident* :
I do hereby declare that the complaint has not been filed before any other Commission/Court earlier.
 
*Marked fields are mandatory  
upload Scaned copy of signature*