Mobiletqqqgoq:

00B doe;' Not

to HOP: of

ndmark: School Area/ Locality/ Sector:

6
Village/Town/City: Thon Post Office:

District: e Sub-District: State: Ma ha—jo

E-Mail: MobileNo.: PINCode:

Detailsof: O Father Mother OGuardian OHusband OWife

for childrenbelow5 Fats father/Mother/Guardian#detailsare mandatory.Adultscan not to specW this *ma60n.
7
m 7 ah Ra •esk,
EID/ Aadhaar N 19 I dd I mm I hi' : mm SSI

Verification Type: ODocument Based Based ÜHead of Family (HOF) Based

Select only one of the above. Select Introducer or Head of Family only if you do not possess any documentary proof of identityand/
or address. Introducer and Head of Family details are not required in case of Document based verification.
8 For
a. POI b. POA

c. DOB d. POR
(Mandatoryin case of Date Birth) (Oandotoryin case of HOF

For HOFBased- Detailsof :ÜFather OMother OGuardian OHusband OWife

For Introducer Based —Introducer's
9 Aadhaar No.: I I I Hors EID/ AadhaarNo.: I I Ill I I i
dd i mm I yyyy I hh : nun:
I hereby confirm the identity and address of as being true. correct and accurate.

Introducer/ HOE's Name: Signature of Introducer/ HOF

Oisdosure under section 3(2) of THE AADHAAR (TARGETED DELIVERY Of FINANCIAL ANO OTHER SUBSIOIES, 6tNEf1TS ANO SERVICES) ACT.2016
bö.metncs)
1confirm that have been residing in india at least 182 days in the preceding 12 months / i am Non Resident Indian (NM) & jntotmaoon(including
providedby me to the UiDAlIs my own and is true, correct and accur.te. am aware that my informationincludingbiometrics willbe used toe generationof
as
and authentication. i understandthat my identity information(except core biometric)may be providedto an agency with myconsentduring
per the provision _AadhaarAct. have a right to access my identity information(except core biometrics)followingthe procedurelaid downbV

verifier's idSiynat'Jte
(Verifier m e, sump Is not available) Applicant8soature/ Thumbprint

To be filled by Inrolrnent only:

Ne•e; ofminw, by to be done by oflitcopdtgtedPenon
• o' only/od/gn w/"be PO'.