Application Fee: Rs.

350/- (DD or Cash)

Gramin e-Mitra (GEM)

Application Form Application Number (office use only):

GEM Location:.. 1. Name: Please affix a Recent Passport Size Photograph of Applicant

2. Fathers/ Husbands Name:

3. Date of Birth:

4. Gender: Male / Female

5. Nationality:

6. Applicants Address: House No. Village Tehsil District State Pin Code

7. Contact Details: Landline No. Mobile No. Fax No. E-mail ID

8. Educational Qualifications: Sr. No 1. 2. 3. 4. 5. Qualification College/ University Year of Percentage/ Remarks Passing Grade

9. Professional Qualification:

10. Skills: 1. 2. 3. 4. 5. 6.

10. Family Business:

11. How did you hear about this project?

Declaration I, Son / Daughter/ Wife of

Shri_______________________________ hereby declares that above furnished information is correct and authenticated and if found any false statement above said for which purely I will be liable for the same. Date: __/__/____ Place:__________

Applicants Signature