| Application Form for Opening a Regional |
| 1. Registration Details / पंजीयन का विवरण * अनिवार्य फिल्डस (Mandatory fields) |
| Registration Number of the Trust/Society* |
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| Name Of The Trust/Society* |
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| Address Of The Trust/Society* |
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| 2. Applicant's Personal Details * अनिवार्य फिल्डस (Mandatory fields) |
| Applicant Name * |
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| Father Name * |
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| Mother's Name / माता का नाम * |
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| Date of Birth / जन्म दिनांक * (MM/DD/YYYY) |
( As per high school certificate in 'MM/DD/YYYY' format. i.e. '01/15/1999' )
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| Category / श्रेणी * |
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| Gender / लिंग * |
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| 3. Contact Details / संपर्क विवरण* अनिवार्य फिल्डस (Mandatory fields) |
| Phone with STD Code / पता * |
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| Mobile Number / मोबाइल नंबर * |
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| Email Address / ईमेल पता |
([email protected])
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| 4. Educational / Qualification Details / षैक्षिक / योग्यता का विवरण* अनिवार्य फिल्डस (Mandatory fields) |
| Highest Educational Qualification / शैक्षिक योग्यता * |
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| Year of Passing / * |
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| Roll No /* |
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| Result /* |
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| 5. Applicant’s Personal Details / आवेदक का व्यक्तिगत विवरण* अनिवार्य फिल्डस (Mandatory fields) |
| Address Line 1/ पता 1 * |
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| Address Line 2/ पता 2 * |
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| Address Line 3/ पता 3 * |
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| City Name/* |
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| State* |
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| District* |
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| Pin Code / पिन कोड * |
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| 6. Name and Address of the Regional Details / * अनिवार्य फिल्डस (Mandatory fields) |
| Regional Name * |
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| Address Line 1/ पता 1 * |
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| Address Line 2/ पता 2 * |
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| State* |
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| District* |
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| Pin Code* |
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| 7. Regional Contact Details / * अनिवार्य फिल्डस (Mandatory fields) |
| Mobile No.* |
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| Email ID* |
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| 8. Regional Application Details / * अनिवार्य फिल्डस (Mandatory fields) |
| Enter Zonal Code of Accreadited Regional |
Zonal Status
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| Selected Zonal State of Accredited Regional / * |
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| Selected District of Accredited Regional / * |
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| For which District Regional has Applied* |
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| 9. Identification Details / पहचान की सूचना* अनिवार्य फिल्डस (Mandatory fields) |
| Voter ID#/Adhaar ID#/PAN # /मतदाता आईडी # / आधार आईडी # / पैन # * |
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| Upload Photo |
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| Upload Signature |
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| Upload Thumb |
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| Upload Center Photo |
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