District Coordinator Form

First Name*

Last Names*

Father / Spouse Name*

Date of Birth*

Sex*

Nationality*

Marital Status*

Educational Qualifications*
Non GraduateDiplomaGraduatePost Graduate

Permanent Address*

Present Address*

Email*

Mobile No*

District*

Language Known*
EnglishHindiMarathiBhojpuriTamilMalayalamTelguKannadOther

Nature of Business*

Occupation*
--Select One--StudentProfessionalSelf EmployedSalariedGov. ServiceRetiredNot EmployedHome MakerFarmerOther

Designation

State*
--Select your State--Andhra PradeshArunachal PradeshAssamBiharChhattisgarhGoaGujaratHaryanaHimachal PradeshJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttarakhandUttar PradeshWest Bengal

Union Territories
--Select Union Territory --Andaman and Nicobar IslandsChandigarhDadra and Nagar Haveli and Daman & DiuDelhiJammu and KashmirLadakhLakshadweepPuducherry

District

Area Ward No/Village

Area Police Station

Name of the Proposer/Introducer

Passport Size Photo* (Required upload size: 5MB)

Signature for ID Card* (Required upload size: 5MB)

Id Proof* (Required upload size: 5MB)

(You can submit your Front and back of Aadhar card as a ID Proof as well as Address Proof.)

Address Proof* (Required upload size: 5MB)

(You can submit your Front and back of Aadhar card as a ID Proof as well as Address Proof.)

Transition Receipt* (Required upload size: 5MB)