ग्राम माइक्रो इंड्रस्ट्रीज डेवलपमेंट अभियान | Gram Micro Industries Development Mission

Trainee Membership Form – 2024 (रजिस्ट्रेशन करे)

PERSONAL DETAILS

Candidate's Name (English) *

अभ्यर्थी का नाम (हिन्दी):

Father's Name/पिता का नाम *

Mother's Name/माता का नाम :

Date Of Birth/जन्मतिथि :

Age As On Date/आज की तिथि के अनुसार आयु :

Gender/लिंग :

Mobile number/मोबाइल नंबर *

Whatsapp number/मव्हाट्सएप नंबर :

Email Id/ईमेल आईडी :

Guardian Contact Details:-

Mobile number/मोबाइल नंबर :

Whatsapp number/मव्हाट्सएप नंबर :

Email Id/ईमेल आईडी :

Permanent Address/स्थाई पता :

Correspondence Address:-

Permanent Village/Mohalla:

Panchayat/पंचायत :

Post:

Block/ब्लॉक :

Police Station:

District/जिला :

Postal Pin Code/डाक पिन कोड :

State/राज्य :

Nationality/राष्ट्रीयता :

Category/श्रेणी :

Aadhaar Number/आधार संख्या :

Pan Number/पैन संख्या :

Educational Details

Certificate	School/Board	Year of Passing	Subject	% of Marks
High School
Intermediate
Others

Experience Details

Name of Organization	Period of Service	Reason for Leaving

Whether Computer Operational Knowledge:

Yes

Attach Photograph/फोटो संलग्न करें : Max file size: 3MB

Attach Signature/हस्ताक्षर संलग्न करें : Max file size: 3MB

Only the training membership fee 560/- (Five Hundred Sixty rupees) was paid by me with the educational consent, which is not payable by the institute. Apart from this, no fee has been paid, nor has been demanded by the institute in the future. This is confirmed and acknowledged by me.

JAN Swasthya Paramarsh Shayata Awam Chikitsha Prashikshan sewa sansthan
Bank Name -Canara Bank
A/c no- 110140976083
IFSC code - CNRB0002873

Attach Payment Screenshot/भुगतान स्क्रीनशॉट संलग्न करें: Max file size: 3MB