i eran racnercoae: §— (I ISTH Enrolment Agency Name :~ Registrar Code :“ Registrar Name Full Name of the Operator/Supervisor= asd SEMI 21s qelgae EIBNAINCEI STEMI IND 1 4 taal Tope nol eet LL oe ‘Radhaar No. of TT Jer the Operator / Supervisor ~ T TT [11 fea, Lo Certificate No. of the Operator / Supervisor - to - Proposed User i/Operator ib. ofthe Operator / Sunervisor~ ot / aU Date The CEES I status ofthe Operator / Supervisor ~ Aetive/Inastive [Disassociated ae ee} eee te of joining with EA as Operator / Supervisor altel ee ‘Month Vear fie ee NENT TI operatox/Supervsor willbe working in Sweep Mode/Permanent Centre in: state Distt: Sub Oise: apes leas aT Tey pee | [I petals of Enrolment Centre in charge /Owner where operatar willbe working < ‘Name of €¢ incharge/Owner - |Aadhaar No of EC incharge/Owner. ~ ot | ‘Mobile No of €C incharge/Owner-Pan No. of & incharge/Owner Owner of the enrolment kit where operator will be working. Name of Person - Ceili Name of Organization: eason for Association of new Operator/Supervisor in the existing center ‘Incase of any further details, the below may be contacted: Aver coormerstevenooreing — ELE Y INET TP IR EAN CK Name: Agency Co-ordinator/State Head/District Head Mobile Number: Date HSB RT a1) Iishereby declared thatthe information and particulars furnished above are true and correct tthe best of my/our knowledge and boi and nothing has been concealed, A * JAYAN’ aes \YANTA PRAMANICKSir/Madam, {Lam wiling to work with 64. as an ‘Operator’ / ‘Supervisor’ My Details areas below- Full Name - Eepsiey em es ae | aot | J Father's Name: Tal = fpaaleatians at eee Educational Qualification: {Please tick a Mark to the appropriate option) 10" 2 Graduation Post Graduation Recent Photograph ‘Aadhaar No. ofthe Operator / Supervisor - SS ° , Certificate No. of the Operator / Supervisor- T ead L ‘Mobile No. of the Operator / Supervisor - ri Email of of | ‘the Operator / Supervisor - CT (oan LT] Itis to affirm Further that, was previously working with the following Enrolment Agency and wilfully joined EA a " {85 Operator / Supervisor. ‘The further details about my employment in concerned area tll date is furnished below- _Date of Joining present Employer/EA as Operator / Supervisor TL ‘ Date ‘Monti I Year ‘The details of previously agency are fErnished below.Previous Enrolment Agency Code: itis hereby declared that the information and particulars furnished above are true and correct to the best of my/our knowledge and belief and nothing has been concealed. Place: Date: Signature of Operator / Supervisor RO OFFI The above request for association of operator with EA have been thoroughly verified after due diligence. The information and particulars furnished above Is found Place Date: Signature of SSA/PMU Place Date: Signature of ADG Incharge/DDG Correct:- Recommended for association with EA Incorrect -Not recommended for association with EAPrevious Enrolment Agency Code: {tis hereby declared that the information and particulars furnished above are true and correct to the best of my/our knowledge and belief and nothing has been concealed. Place: Date: Signature of Operator / Supervisor FI The above request for association of operator with EA have been thoroughly verified after due diligence. The information and particulars furnished above Is found Place: ate Signature of SA/PMU Place: ate Signature of ADG incharge/006 Correct:- Recommended for association with EA Incorrect -Not recommended for association with EA