DDU-GKY Ministry of Rural Development, Government of India: Bishan

1|Page
SF6.2A3: Candidate Application Form
Bishan Rukmani Memorial Foundation

DDU-GKY Ministry of Rural Development, Government of India
Project Number 52 DL2021RF37015
State Haryana
Training Centre Name Bishan Rukmani Memorial Foundation
C/O Sadha Sukh Public School Gahra Road,Kanina, Mahendergarh
Address of Training Centre
Haryana-123027
Nearest Police Station Kanina
Batch Number 65E80A115C2EE
Trade Two Wheeler Service Technician-ASC/Q1411
Kaushal Panjee ID W06240061871
Registration Number 3151679
Date of Registration 01-03-2024
Training Duration 616 Hours
To be filled by Candidate:
A. Trainee Profile
Name of Candidate: SAPEN

Father’s Name: AASAM KHAN
Gender Male Female Other
Date of Birth -- 1/2/2002 Age
Contact Phone Number Mobile Home
8818092721
Photo
Email
Facebook Username
Marital Status Single Married Divorced Widowed

Religion of the Candidate Hindu Muslim Sikh Parsi
Buddhist Christian Jain Other

Current Student Yearly Income of the 0
Status (Please Specify) Candidate (in Rs.)
Working
Other
52This section is to be filled by PIA after· successful selection of the candidate

2|Page
Highest Qualification 10th Passing Year
University/Board of Percentage/Grade
Highest Qualification
Technical ITI Other Other, Please Specify

Qualification
Previously Under Yes No If Yes, Please Specify
Gone Skill Training Name of Program
Work Experience Yes No If Yes, Please Specify

Number of Years
Type of Work Location of Work
Aadhar Number Enrolment No. (EID)
Job Card Number / RSBY Card Number53

NREGA
BPL Ration Card No
Antyodaya Anna Driving TWO-

Yojana Ration Card License WHEELER
Number Number LMV
Own a Bank Account Yes No Name of Bank
Do You Have Any Yes No If Yes, Please Specify PMSBY54 PMJJBY55

Insurance Coverage
Other :
Category SC ST Native Language
Language Native Read Write Speak

Known
(Basic, Hindi Read Write Speak
Medium, English Read Write Speak
Good,
Other: Read Write Speak
Excellent)
PWD Type, Please Chronic Disease If Any, T.B. Epilepsy
Specify If Applicable Please Specify
Other:
B. Family Details:
Name of Head of The Marital Status of Single Married

Family Head of The Family
Widowed Divorced
Occupation of The Farmer Labourer Other, Please Specify
Head of The Family
Number of Members Number of Family Members

in The Family Working Side Village
Is Any Family Member Yes No Name of SHG

of Candidate an SHG
Member?56
Monthly Income of Monthly Expenses
the Family (In Rs.) of the Family (in Rs.)
3|Page
Name of Family Relation Phone Age M/F Highest Occupation Monthly Enrolled
Member Number Level of Income in
Education (In Rs.) NREGS
or Skill
Training
Father M
Mother F
Total Land Owned by Agricultural Land

Family (In Acres) (In Acres)
C. Residence Details:
Present Near
House Number:
Address: Landmark :
Street: Block: KANINA
Village KHERI Police Station: KANINA
Post Office: KANINA District: Mahendragarh
Gram Panchayat: KHERI Pincode: 123027
State: HARYANA
Permanent Near
Address: House Number: Landmark :
Street: Block:
Village Police Station:

Post Office: District:
Gram Panchayat: Pincode:
State:
Own house Yes No Electricity Availability Yes No
Number of Living Rooms in Number of Vehicles in House

House
Type of Cooking Material Biogas: Coal: Electric Stove:
Used (Check All Applicable)
Wood: Kerosene: LPG:
Smoke Less Chulha: Cowdung: Other:
D. Candidate Interests and Preferences

4|Page
Trades You Are Interested 1. 2. N.A. (I Am Open To Any

In Trade)
Preferred Duration of 3 Months Salary Expectation

Training After Training:
Have You Met Any Alumni No Yes If Yes, Please
from The Training Program Specify How Many:
Have You Met Any No Yes If Yes, Please

Employers Specify How Many:
Is Any of Your Family or No Yes If Yes, Please
Friends Planning to Join Specify How Many:
the Training Program with
You
Are You Willing to Migrate No Yes, Willing to Migrate Yes, Willing to Migrate
for Training Within the State Anywhere for Training
for Work Within the State Anywhere for Work
What Motivates You to Job Certification Other, Please Specify:
Join the Training
Plan to Continue Studies Yes No Uncertain
After Training
How Did You Hear About Training Centre
This Training Gram Panchayat Friends
Representative
Family Other, Please Specify
Declaration of Guardian57
I,________________________________________S/OiW/OiD/O ________________________________
Hereby Declare That Information Provided By The ____________________________________ Above
Is True And Correct. I Also Declare That He/ She Does Not Have Any Police Case Pending. I Hereby
Give My Approval to Be Held Accountable For _____________________________________ (Name of
Candidate) Indiscipline I Dropping Out from Training/Job After One Year of Joining of The DDU-GKY.
Relation to Candidate:
Address:
Phone No:
Occupation:
Date of Birth(dd/mm/yyyy):
I Understand That I Can Be Contacted by Any Private/Government Agency Involved In DDU-GKY For
Any Further Query Related to Candidate for A Period of 18 months.
Date Signature of the Guardian
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

D/O____________________________________ Hereby Declare That The Information Provided Above Is
True To The Best Of My Knowledge & Belief.
If Selected for Training, I Hereby Undertake:
 To Attend and Participate in All the Sessions/Classes of The Aforesaid Training Program Diligently;
 To Maintain Discipline and Follow the Instructions of The Trainer, While Undergoing the Said
Training Program;
 To Successfully Complete the Training Program; And
I Understand That I Will Be Deemed Ineligible for Assessment and Certification Unless, I Fulfil the Above
Criteria and Meet the Assessment Standards.
Signature of the Candidate
 The Following Documents Are Attached:

 2 Photos
 Photo Identity Proof (Aadhar Card Voter ID/ Driving Licence or Any Other ID/Card Issued by Govt.
Of India)
 Proof of Educational Qualification (Copy of Educational Certificates, Self-Attested)
 Document as Proof of Domicile (Ration Card or Any Other)
 Document as Age Proof
 BPL Card or Certification by Panchayat Authority/ Job Card (MNREGA)/ RSBY Card/ Antyodaya
Anna Yojana Ration Card/ SHG Certificate
 Proof Of SC/ST/OBC/ Minority/PWD, If Applicable
Signature of Applicant
Bank Account Tracking
I, ________________________________ Son/Daughter/Wife Of__________________________________

Here by Allow Ministry of Rural Development to View My Bank Transactions, In Order to Track Timely
Receipt of My Salary and Benefits That I Receive in My Bank Account, For A Period Of 18 Months.
Bank Account Number:
Name of Bank:
Branch Name:
District:
IFSC Code:
Date: Signature of the Candidate

6|Page
Candidate NPRT in House hold Tin No

Number (from (from SECC59)
SECC 58)
Aptitude Test Yes No Name of the test
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
To be filled by PIA/Officials:
Remarks by Trainers/Mobilizer Who Have Interacted with The Candidate:
 Soft-skills trainer:
 Domain trainer:
 Mobilizer:
Selected-for Training: Yes/No
If no, reason for elimination:
Signature of PIA Representatives
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: VISHRAYAL

Father’s Name: SAROJ KHAN
9050197770
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block:
Village KHERI Police Station:
Post Office: District: Mahendragarh
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SAHJAD

Father’s Name: MAHMOOD
7850058366
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block: NIZAMPUR
Village Islampura Police Station: NIZAMPUR
Post Office: NIZAMPUR District: Mahendragarh
Gram Panchayat: Islampura Pincode: 123023
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: AFJAL

Father’s Name: AAMIN
9896168259
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: IRFAN

Father’s Name: SUBHAN MOHAMMAD
8901857687
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: IBRAHIM KHAN

Father’s Name: HUSHIN KHAN
9050197767
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SHAYAD

Father’s Name: RAHEESH KHAN
7495090772
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SADDAM HUSAIN

Father’s Name: LILA KHAN
8818092720
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: JAKIR HUSAIN

Father’s Name: RIJAK
8278008808
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: PRIYA

Father’s Name: ZAMIL KHAN
981345832
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block: MATANNAIL
Village KHANPUR KHURD Police Station: MATANNAIL
Post Office: MATANNAIL District: Jhajjar
Gram Panchayat: KHANPUR KHURD Pincode: 124142
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SADDAM KHAN

Father’s Name: AKBAR KHAN
8307914759
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block:
Village KHERI Police Station:
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: FIROZ KHAN

Father’s Name: BABU KHAN
8930226206
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SARAAFDEEN

Father’s Name: LILA KHAN
9350082615
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: HUSAIN ALI

Father’s Name: KASHMIR ALI
9588758035
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block: TOSHAM
Village CHIRIYA Police Station: TOSHAM
Post Office: TOSHAM District: Bhiwani
Gram Panchayat: CHIRIYA Pincode: 127022
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: HASAN ALI

Father’s Name: KASHMIR ALI
9588758034
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block: TOSHAM
Village CHIRIYA Police Station: TOSHAM
Post Office: TOSHAM District: Bhiwani
Gram Panchayat: CHIRIYA Pincode: 127022
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: IRFAN

Father’s Name: HUSAIN KHAN
8569943090
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: MOMIN KHAN

Father’s Name: NISAR MOHMAD
8307479339
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2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: ARMAN

Father’s Name: Sabir Khan
9897867560
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Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Village Kanina Rural Police Station: KANINA
Gram Panchayat: Kanina Rural Pincode: 123027
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: AFSANA

9050581491
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: MUSKAN

Father’s Name: ASLAM
8307234652
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block:
Village Islampura Police Station:
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SAJID KHAN

Father’s Name: SHARIF KHAN
9729290353
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Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Street: Block:
Village Islampura Police Station:
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: JAKIR HUSSAIN

Father’s Name: ARIF KHAN
7082270832
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Email
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2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Village GANWARI JAT Police Station: NIZAMPUR
Gram Panchayat: GANWARI JAT Pincode: 123023
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: TOFIK

Father’s Name: MOHAMAD ASLAM
8295135955
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: YASHMIN

Father’s Name: GANI RAM
7206135083
Photo
Email
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Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Village KANINA RURAL Police Station: KANINA
Gram Panchayat: KANINA RURAL Pincode: 123027
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: NARGIS

9729981958
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SHABNAM

Father’s Name: ABDUL GANI
9729981959
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: AMINA

9050581492
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: NAEEM KHAN

Father’s Name: BABU KHAN
8930520670
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
Village NANGAL DARGU Police Station: NIZAMPUR
Gram Panchayat: NANGAL DARGU Pincode: 123023
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: VASIM

7206135082
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SHAHRUKH KHAN

Father’s Name: SADDU KHAN
8295254298
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: ARMAN

Father’s Name: VAHID
8295259649
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: VINOD

Father’s Name: RAJBIR SINGH
9729473574
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SOHID

Father’s Name: ALTAF
9034431655
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: SALMAN

Father’s Name: USMAN
9050567988
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
1|Page

State Haryana
Haryana-123027
A. Trainee Profile
Name of Candidate: MUSRAF

Father’s Name: RIZAK
9050197769
Photo
Email
Facebook Username


Working
Other

2|Page

Qualification

Number of Years

NREGA
BPL Ration Card No

Number Number LMV

Insurance Coverage
Other :

Known
Good,
Excellent)
Other:
B. Family Details:

Widowed Divorced
Head of The Family


of Candidate an SHG
Member?56
3|Page
or Skill
Training
Father M
Mother F

Present Near
House Number:
Address: Landmark :
State: HARYANA
Permanent Near
Street: Block:

State:

House

4|Page

In Trade)


You
Join the Training
After Training
Representative
I,________________________________________S/OiW/OiD/O ________________________________
Address:
Phone No:
Occupation:
Self-Declaration:
5|Page
I, _____________________________________ S/O / W/O /

Training Program;

 2 Photos
Of India)

Name of Bank:
Branch Name:
District:
IFSC Code:

6|Page

SECC 58)
Conducted Conducted
Aptitude Test Score
Allocated Trade
Comments if any
 Domain trainer:
 Mobilizer:
Name:
Designation:
7|Page

DDU-GKY Ministry of Rural Development, Government of India: Bishan

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1|Page

SF6.2A3: Candidate Application Form

Bishan Rukmani Memorial Foundation

Name of Candidate: SAPEN

Marital Status Single Married Divorced Widowed

Buddhist Christian Jain Other

52This section is to be filled by PIA after· successful selection of the candidate

Highest Qualification 10th Passing Year

Technical ITI Other Other, Please Specify

Work Experience Yes No If Yes, Please Specify

Aadhar Number Enrolment No. (EID)

Job Card Number / RSBY Card Number53

Antyodaya Anna Driving TWO-

Own a Bank Account Yes No Name of Bank

Do You Have Any Yes No If Yes, Please Specify PMSBY54 PMJJBY55

Category SC ST Native Language

Language Native Read Write Speak

Name of Head of The Marital Status of Single Married

Number of Members Number of Family Members

Is Any Family Member Yes No Name of SHG

Total Land Owned by Agricultural Land

Village KHERI Police Station: KANINA

Post Office: KANINA District: Mahendragarh

Gram Panchayat: KHERI Pincode: 123027

Village Police Station:

Number of Living Rooms in Number of Vehicles in House

Smoke Less Chulha: Cowdung: Other:

D. Candidate Interests and Preferences

Trades You Are Interested 1. 2. N.A. (I Am Open To Any

Preferred Duration of 3 Months Salary Expectation

Have You Met Any No Yes If Yes, Please

Family Other, Please Specify

Date Signature of the Guardian

I, _____________________________________ S/O / W/O /

If Selected for Training, I Hereby Undertake:

Signature of the Candidate

 The Following Documents Are Attached:

Bank Account Tracking

I, ________________________________ Son/Daughter/Wife Of__________________________________

Bank Account Number:

Date: Signature of the Candidate

Candidate NPRT in House hold Tin No

Aptitude Test Score

Remarks by Trainers/Mobilizer Who Have Interacted with The Candidate:

Selected-for Training: Yes/No

If no, reason for elimination:

Signature of PIA Representatives

SF6.2A3: Candidate Application Form

Bishan Rukmani Memorial Foundation

Name of Candidate: VISHRAYAL

Marital Status Single Married Divorced Widowed

Buddhist Christian Jain Other

52This section is to be filled by PIA after· successful selection of the candidate

Highest Qualification 10th Passing Year

Technical ITI Other Other, Please Specify

Work Experience Yes No If Yes, Please Specify

Aadhar Number Enrolment No. (EID)

Job Card Number / RSBY Card Number53

Antyodaya Anna Driving TWO-

Own a Bank Account Yes No Name of Bank

Do You Have Any Yes No If Yes, Please Specify PMSBY54 PMJJBY55

Category SC ST Native Language

Language Native Read Write Speak

I, Son/Daughter/Wife Of__

I, Son/Daughter/Wife Of__

I, Son/Daughter/Wife Of__