cts ANN. UALR we Fe nr a ape tea es ces EU osname ceditualh cu Bu dS aueF deed sual el, yard suceucih dd dh a EID, tr AF Powel yard Ravll daa Rom amanda, Incase of Correction provide your EID No. here J 2(1l2) seit deel cous EID ioe dl ed Please follow the instructions overleaf while filing up the form, *u de ort wet Wusen Heel a-tIHiL GiAil, Use capital letters only, wulSedl Size 21am all, ‘Agency Name / eral 0, Agency Code wrth AADHAAR ENROLMENT / CORRECTION FORM aur diaell / yeu ga 1 | Pre-Enrolment 10 ital dated si ya 2_ [NPR ReceipvTIN Number / NPR vi | TIN “ea 3 | FulName /=0§ a0 4) | Gender / fee 5 | Age! Gee: Yratel OR/teA Date of Birth / 4a: Male 43%: ( ) Female el: ( ) Transgender 4 ( ) Declared waiter Verified / asa © | Address /aeutpCio( _) Biot) SoC) Wo) Hi) House NovBldg /Apt/ esti StrettRoadiLane / > Landmark / 254 nd re ‘ail ocalityiSector/ PeaeRs28 VilagerToun/ City / areas Post Office / ie a Distict/ Fe: ‘Sub-Disiet/ wi State / ve: E Mail Ba: Mobile No aa PIN GODE /t as 7 | Details of/ Goud: Fatherffst( ) Motherutt ) Guardians) Husband ) Wier) For chen below 5 years Fatner/Mothe/Guardan'sdetais are mandatory. Adults can opto rat spect ths informaton, hey canncid not want to discose eed ra eA 2 yeaa ae SB, ye el aA 2 Rael ane AS 3, Name /0 EID/ Aadhaar No / EID alu “oe 8 | have no Objection to the UIDAI sharing information provided by me tothe UIDAI with agencies engaged in delivery of welfare services. UIDAL a see, asa al ine Sad MLL UIDAT = ane ate el area 248 AL a el Yesiai( ) Nott ( 9 | Select one ofthe Below (OPTIONAL) (Tis data cannot be Corected after Enrcient) aie sie Rs eB, ual ge el 4 lie me ai Se ee a tl, (Cl! want the UIDA\ to facitate opening ofa new Bank/Post Ofce Account linked to my Aadhaar Numiver and have no objection to information fortis purpose, UIDAI + zal es / nz =iIBHON iG Mg Mle MO 2A ALE ll HOA HAL ARIA [C11 have no objection o linking my present bank account proved here to my Aadhaar number. sa ane ae Ma ae es la a a et AA A ALES el State uae Bank NametBranch Ss a IFSC Gode FSC Ss: ‘Account No Fat 2: Verification Type / sel use: Document Based /cauty stfu) Invodueer Based /eimasd afufia( ) Head of Family / gga ( ) Select only one ofthe above. Select Introducer or Head of Family only i you donot possess any documentary proof of entity andor address Introducer and Head of Family details are not required in case of Document based Verification Gthibl ta 4s Wee, 3, 4s AEA MAL gE a A A Re hair cane ee 3 een ype tae, silos ek el Pile aan sel sl gL ell For Document Based (write Names ofthe doc ents produced, Refer backside ofthis form or letof valid documents) 10 | cay tale (ater are ae OU, Med al El Hd aA HEIL AED) AL POI eden yee B._ POA. sand ©. DOB sess yee: D. POR- ited yaa: (anes n caf Vr Da of a) (ws eae un) 11 | Forintroducer Based (=i =a a For HoF Based - Details of gon au allen Wi - Ro Introducers Aadhaar No. sit steal aa ne Featheifet( ) Mothers ( ) Guariansudl( ) Husband ( ) Wier ) HoF's El Andhaar No 2 ud EID ba vine "hereby conf the identy and address off wed ts 3 5 beng rue, corect and accurate ft io 4 aura, Hom eB. IntroducertHoF's Name /»iirlsgoa ay He ‘Signature of introducer MOF eras eu tel al Consent si | confirm that information (including biometrics) provided by me tothe UIDA and the information contained herein is my own and is true, correct and accurate, Ghul aay 3 ea at UIDAM aad ae Pall ke al ae eed B a (ese ae) ate, oa ed a B. Verifies Stamp and Signature / ste sf al 24% Bu Applicants signature/Thumbprint (Meter mat uta Name, tr nts al Sk le is, Bat seeratll al tel oe ‘Tobe filed by the Enroiment Agency Only. Date & tine of Enveiment:COs Se PR ea cee Cs V.PANNO/ A wt sg wt Gard No lt ine 2 IG Card Nol eal a eR <—_____ spy car No). as 3. LPGIPNG Gas Connection No ea 7. Disabiity 9 =asect arth £8. 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