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E Shram Card Registration Application Form

The document is an application form for E SHRAM Card registration, requiring personal details such as Aadhar number, name, gender, date of birth, and contact information. It also includes sections for nominee details, address, qualification, income, occupation, and bank account information. The applicant must declare the truthfulness of the information provided and confirm they are not a member of ESIC/EPFO or an income tax payer.

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SURESH BABU
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1K views2 pages

E Shram Card Registration Application Form

The document is an application form for E SHRAM Card registration, requiring personal details such as Aadhar number, name, gender, date of birth, and contact information. It also includes sections for nominee details, address, qualification, income, occupation, and bank account information. The applicant must declare the truthfulness of the information provided and confirm they are not a member of ESIC/EPFO or an income tax payer.

Uploaded by

SURESH BABU
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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E SHRAM Card Registration

Application Form

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Aadhar Number___________________________Name: ______________________________
Gender : ______________ Date of Birth : ______________________Blood Group__________

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Personal Details
Mobile Number

Emergency Mobile Number

Marital Status

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Father/Husband / Wife Name

Social Category

Differently Abled
H Nominee Details
Nominee Name

Gender

Relationship with UW
S
Date of Birth

Address
W

Home / Native state

Home / Native district

Current Address

Staying at current location


GS

Permanent Address With House No

Qualification and Income Details

Qualification

Monthly Income

Primary Occupation
Working experience in Primary
Occupation
How did you acquire Skills?

Sub Skill

Bank Account Detail

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Bank Account Seeded with Aadhaar

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Bank Account Number

Account Holder Name

IFSC Code

Bank Name

Branch Name

Declaration

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I solemnly declare that all the information furnished in this registration form is true to the best of
my knowledge. I take the responsibility for the correctness of the information furnished by me for
this registration.
H
Further it is declared that

1. I am not a member of ESIC /EPFO.


2. I am not a income tax payer.

3. All the information provided by me may be validated at the time of receipt of any scheme
S
related monetary benefits under social security code of government of India.

I undertake that, I am neither a member of Government services/PSUs, nor an income tax


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payee. I also undertake that the information furnished in the registration form is true to the best
of my knowledge. If any of the fact(s) provided by me is found to be incorrect, I shall be liable
for legal action as deemed appropriate.
GS

Signature of the Applicant

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