Fetch UID Detail :
Aadhaar Number :          
                 
Upon Final selection of the applicant Aadhar is mandatory and VLE must submit the same.
Applicant :
Applicant Name : *        
                 
Family Detail :
       
       
Father's / Husband's Name : *   
     
 Mother's Maiden Name   : * 
     
Family Annual Income : *
     
Applicant's Photograph :
Size of Photograph should be between 5KB to 20KB and height / width should be  4.5 cm by 3.5 cm. The file format needs to be in .bmp / .jpg / .png
Attach Image  :    *

Residence Address :
Care Off :  
     
Road / Street Name : * 
       
Locality :  
       
Tehsil / Taluka :  *
         
 Pin Code : *
     
 
House No./ Room No./ Building : * 
         
Landmark :  
       
District : *
     
Village / City / Town :  *
     
Applicant Detail :
Date of Birth : *
     
Gender : *
     
Mobile No. : *
     
Phone No. :  
     
 
Age : * (Years)  
                     
Physically Challanged : *
       
Email ID : *
     
PAN No. : *
     
Proposed Center Address :
House No./ Room No./ Building :  *
     
Locality :  
       
District : *
     
Village / City / Town : *
     
 
Road / Street Name : *
       
Landmark :  
       
Tehsil / Taluka :  *
     
 Pin Code : *
     
Nearest Bank Name : *
     
 
Branch Name of the Bank : * 
       
Evaluate Yourself :
     
Educational Qualification : *
     
Computer Certification :  *
     
Distance of Proposed Center from Residence :  *
     
Shop Size :  *
     
 
Computer Experience : *
     
Residing at above Residential address since : *
     
Current Business :  *
     
Shop Ownership  :  *
     
Reference Detail :
Detail of two well know person of your village who knows you well
     
1st Reference Name : *
     
2nd Reference Name :  *
     
 
1st Reference Contact No. : *
     
2nd Reference Contact No. : *
     
General Information :
Load Shading timing : *  (in Hrs)
     
 
Own Power Back-up availability : *  (in Hrs)
       
User's Verification :
 Verification Image :  
 
 
      Values are Case Sensitive
Enter the text as in the image : *
     

Declaration :  

I declare that the information that I have provided is correct and to the best of my knowledge. I understand that this information will be used to determine my eligibility to be appointed as a VLE and to allot new CSCs, I have been informed that I must provide the required documentation within 15 days from the date of intimation of my selection as a VLE, in order to complete the allotment process on selection. I understand that if I do not provide the required documentation, with in stipulated time period, my application will not be considered for the center allotment and SCA will continue with the allotment process.
       
 I Accept : *