`Application form for Independent Individual Worker's`

To be issued From

Applying to *

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Please Enter the Mobile Number and the Reference Number of the Previously issued Output Certificate

Mobile Number *

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Reference Number *

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Applicant Basic Details

Salutation *

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Applicant Name *

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Mobile Number(Applicant)

E-Mail(Applicant)

Relation *

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Name(Applicant's Next of Kin) *

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Mobile Number(Applicant Kin)

Religion *

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Date of birth *

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Gender *

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Aadhar Number

Health status

Health status *

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Please specify if any co-morbidities

Blood group *

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Permanent Address

Address Line 1(Permanent) *

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Address Line 2

Address Line 3

Country

State

District

Sub-division *

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Village/City *

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Ward Number

Police Station *

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Postal / Zip Code

Current Address

Name of House Owner *

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Contact of House Owner *

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Address Line 1(Current Address) *

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Address Line 2

Address Line 3

Country *

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State *

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District

Sub-division *

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Village/City *

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Ward Number

Police Station *

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Postal / Zip Code *

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Name of GPU/DZUMSA/NP/MC/GMC

Applicant Occupational Details

Date of Entry in Sikkim *

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Trade *

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Work Location *

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Employment status *

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Name of Employer/Service provider *

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Employer mobile Number *

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Address Of Employer *

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Signature of Employer *

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Applicant Photo

Min 20: Max: 350(Kb)

Applicant Image *

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Applicant Signature *

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Declaration

I hereby solemnly affirm and declare that to the best of my knowledge and belief :

I have not concealed or suppressed any information, the disclosure of which would make me disentitled for this Certificate.
I shall be held responsible for any misrepresentation or false information given by me while applying for this Certificate.

Valid till

I Agree *