Format for claim an Operator / Supervisor to associate on the UIDAI adrnin portal under EA Code

Operator'slSuPervisol's Format-

Sir/Madam,
with EA ,.INDIAN BANK NEW 0651. as an 'Operator'/ 'suPervisor'
I am willing to work
My Details are as below-
FullName:

[.{ 1 m A N s H U S h A R rn A
Fathe/s Name:

s H A t L E NI D R n K u frr R R
Address:

hr A R D l.[ o 6 th o rl ft L L n p ft r vh
'l) A q A L
I
A I I A p IJ P. ? R a T "r_ lr) o T T H * R
n l) D t} IJ NI
r) T fr R r P R t+ D € s H
Educational Qualification:
(Please tick a Mark to the appropriate option)
10th 12th
Aadhaar No. of the Operator

3 +la L 5
/
Graduation
SuPervisor -

6 q 6 g 5 I
Post Graduatlon
# -&
Certificate No. of the OPerator
I
/ Supervisor - *wrl
(
r{ S 6 3 6 6 r..,, 7
Mobile No. of the OPerator / Supervisor -

B 6 3 D 7- L slq € 5
Email lD of the OPerator I Supervisor -

h B 0 3 E
tr 1 (olq nt a I ) el" n
to affirm further that, I was previously working with the following Enrolment Agency and
willfully joined EA
It is
INOIAN BANK NEW as Operator / Supervisor'

The further details about my employment in concerned area till date is furnished
below-
Date of Joining present Employer/EA as Operator / Supervisor

Date Month Year

The details of previously agency are furnished below.

Name of the / Enrolment

Enrolment AgencY Code:

It is hereby declared that the information and particulars furnished above are true and correct to the best of my/our
knowiecige and beiief and nothing has been conceaied.

Place:
Date:
Cogn6-or..,
al[as lN*zo-
r{.-l'
Signature of Operator / Supervisor

RO OFFICE

The above request for association of operator with the EA have been thoroughly verified after due diligence.
The information and particulars furnished above is found

Correct

lncorrect
tl
Place:

Date: Signature of SSA/PMU

Place:

Date: Signature of ADG lncharge/DDG

Correct: Recommended for association with EA

lncorrect: Not recommended for association with EA

 UNDER TAKI NG

t, shri/
smt ... .............. H. mI n.N. s. H.u_.......... ..5 fi..n. fr. {I. fr Bearing
certificate ruo """'NS '6.3.6.'6..5..7......-. .-working as
operator / supervisor with the Enrolment Agency
.Ynsril . r NEp B ft6 il cS- Cer,rp (ftr/_ Bnxx,) do state that,
I am aware of the guidelines on enrollment issued by UIDAt and I hereby
state that during Aadhaar Enrollment,
lwill not indulge in any kind of fraudulentactivity, corruption, disclosure
of personalinformation, misbehavior
Towards the resident, including taking Photo
on Photo (Pop) ; failing witch I will be liable to face legal panel
Proceeding and/or termination including blacklisting
of my credentials as Enrollment operator.

whatever stated in the staternent is true and correct to

the best of my knowledge and belief. I have given the
undertaking without any coercion, threat or undue influence
and while in sound state of mind.

Place: GuR,,ou signature ,+)pl'lt

Date
os [rs f zo2z Msbire' 863o7/3qSS