EA REQUSET FORM FOR OPERATOR / SUPERVISOR ASSOCIATION ENROLMENTAGENCY Cove: | 2 | 1 [8 | 9 ENROLMENT AGENCY NAME :| ¢ | | © s|Piv REGISTER CODE: 2lol6 REGISTER NAME: E GOVERNANCE SERVI INDIA LIMITED FULL NAME OF THE OPERATOR / SUPERVISOR : AADHAAR NO. OF THE OPERATOR / SUPERVISOR : CERTIFICATE NO, OF THE OPERATOR / SUPERVISO! PROPOSED USER ID / OPERATOR ID. OF THE OPERATOR / SUPERVISOR: STATUS OF THE OPERATOR / SUPERVISOR -{ ACTIVE/INACTIVE/DISASSOCLATED) : DATE OF JOINING WITH EA AS OPERATOR / SUPERVISOR : MMYYYY¥ pia|RiMja N{E| NIT OPERATOR / SUPERVISOR WILL BE WORKING IN SWEEP MODE / PERMANENT CENTER IN STATE: DISTRIC : SUB-DISTRI DETAILS OF ENROLMENT CEN NAME OF EC INCHARGE/OWNEI OWNER WHERE OPERATOR WILL BE WORKING ‘ADDRESS OF BC INCHARGE/OWNERAADHAAR NO, OF EC INCHARGE/OWNER : MOBILE NO OF EC INCHARGE/OWNE! PAN NO OF EC INCHARCE/OWNER : OWNER OF THE ENROLMENT KIT WHERE OPERATOR WILL BE WORKING NAME OF PERSON : NAME OF ORGANIZATION : MOBILE NO. OF KIT OWNER : REASON FOR ASSOCIATIONOF NEW OPERATOR/SUPERVISOR IN THE EXISTING CENTER : In case of any further details, the below may be contacted Agency Co-Ordinator / State Head / District Head Name: Pia yjajNoTla P[R]A|M|A|N Agency Co-Ordinator / State Head / District Head Mobile No: [e]«] 7\5 8/5/9 1]4}1}3 fa Itis hereby declared that the information and particulars furnished above are true and correct to the best of my/our knowledge and nothing has been concealed. Seal & Signature of Technical Co-Ordinator / State Head of Enrolment Agency PLACE : Kolkata, DATE:OPERATOR / SUPERVISOR CONSENT FORM FOR ASSOCIATION WITH EA SIR/ MADAM, 1AM WILLING TO WORK WITHEA CSCSPV AS AN ‘OPERATOR’ / ‘SUPERVISOR’ FULL NAME = FATHER’S NAME : ADDRESS EDUCATION QUALIFICATION pr jx (Please tick a Mark to the appropriate option) 10” a2" GRADUATION POST GRADUATION ATTACHED, AADHAAR NO, OF THE OPERATOR / SUPERVISOR : PASSSPORT SIGE PHOTOGRAPH CERTIFICATE NO, OF THE OPERATOR / SUPERVISOR : ‘MOBILE NO OF THE OPERATOR / SUPERVISOR : EMAIL OF THE OPERATOR / SUPERVISOR : It is to affirm further that, | was previously working with the following Enrolment Agency and Willfully joined EA as OPERATOR / SUPERVISOR the further details about my employment in concerned area till date is furnished below ~ DATE OF JOINING PRESENT EMPLOYER/EA AS OPERATOR / SUPERVISOR DDMMYYYyY ‘The details of previously agency are furnished below NAME OF THE PREVIOUSLY EMPLOYER / ENROLMENT AGENCY: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: Signature of OPERATOR / SUPERVISOR DATE: RO OFFICE ‘The above request for association of operator with EA have been thoroughly verified after due diligence. The information and particulars fumnished above is found. Correct Incorrect Signature of SSA/PMU Place: Date: Signature of ADG Incharge/DDG Correct := Recommended for association with BA Incorrect :- Not recommended for association with EAUNDERTAKING I, Shri/Smt working as operator / Bearing Certificate No. ....... Supervisor with the Enrolment Agency...CSCSPV..(EA code 2189 ), do state that , | am aware of the guidelines on enrolment issued by UIDAI and [ hereby state that during Aadhaar Enrolment . | will not indulge in any kind of fraudulent activity . corruption, disclosure of personal information, misbehaviour towards the resident, including taking Photo on Photo (POP) : failing which I will be liable to face legal panel proceeding and/or termination including blacklisting of my credentials as Enrolment Operator. Whatever stated in the statement is true and correct to the best of my knowledge and belief. I have given the undertaking without any coercion, threat or undue influence and while in sound state of mind. Place : Signature Date : Mobile :