* Full Name:

* Date of Birth:

* Father's/Husband's Name:

* Gender: --select-- Male Female Other

* Religion: OTHERS --select-- HINDU ISLAM CHRISTIAN SIKHISM JAINISM BUDHISM

* Marital Status: OTHER --select-- SINGLE MARRIED WIDOW

*Whether belongs to
GEN/OBC/EWS/SC/ST: GEN --select-- OBC EWS ST SC

*Documentary proof to be enclosed
in case of OBC/EWS/SC/ST: NO YES

* Whether belongs to Ex-Servicemen: NO --select-- YES

* Persons with Benchmark
Disability: NO --select-- YES

* Nationality: --select-- INDIAN

* State: --select-- Andhra Pradesh Andaman and Nicobar Islands Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadar and Nagar Haveli Daman and Diu Delhi Lakshadweep Puducherry Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

* District:

* Pin Code:

* Permanent Address Same as Above:

* State: --select-- Andhra Pradesh Andaman and Nicobar Islands Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadar and Nagar Haveli Daman and Diu Delhi Lakshadweep Puducherry Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

* District:

* Pin Code:

* Nearest Railway Station:

* e-mail:

Official Telephone Number:

* Mobile Number:

Aadhar: