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Bel Reg Form

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Application Form

Personal Details

Fill the Form in BLOCK LETTERS

1.Name of the Applicant :-……………………………………………………………………………

2.Father’s /Husband Name:-……………………………………………………………………………

3.Present Address :-………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

4. Permanent Address :-……………………………………………………………………………………………………………….

District :-…………………….…….Block :-………………………………….Panchayat :-………….……………………………

State :-………………….Contract No:-…………………………/……………………….…..Pin Code:-……………………….

5. E.mail Address…………………………………………………………………………….Password:-………..………………….

6. Category :-Gen/OBC/EBC/SC/ST 7. D.O.B.:-…………/…………/…………..8. Gender/Sex:-………...………

9. Challan Number :-………………………………………………………………………………………………………………………


Name of Board/ College/School Year of Full Mark’s % Grade/
Passing Mark’s Obtained Obtained Division
College Name
High
School

Inter
Degree
Post
Graduation
Others
Mandatory Documents. (Please Tick √ )
1. Date of Birth Proof :- Matric Marksheet / Matric Certificate
2. Intermidiate. :- Marksheet /Certificate 3. IA/ISc/ICom 4. Caste Certificate (if - yes):………
5. B.A/B.Sc/BCom (if – yes) – Subject :-……. ……………………. 6. Challan BSEDC’S Copy:-………….
7. Computer Certificate:- ……………………………………………. Duration-One year
8. ID Proof(any one):-Aadhaar Card/Pan Card/Driving Licence/Voter ID/Admit card (Matric)
9. Address Proof(any one):- Domical(Niwas)/Bank Passbook/Voter Id/Aadhaar/Driving licence

Place:-
Date:-

Applicant signature

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