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4, Samim: (Grain tiem)*
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Venue of Enrolment Station/Centre / fear:
Date & Time / feaias aftr tas:
‘Signature of Authorised Person - Agency Name
ate eae ee) - sina ceri afte show wh Enrolment Form No. / avi te mais
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Please use CAPITAL Letters (quatre ranma *nT) Aadhaar/Enrolment number:
Date (feri@) .... emer / fet wore
PartA- Primary Details / (a) eft anfgctt
em BELO pas
Sireire
Name (=a):
Date of Birth: 3-4 TEE: ..: Hnotknown, Age: Sree sTfBeht eIeaes. sar Ta:
Gender: |; Male Female Transgender
fim: yer st oa
Residential address: e721 FT:
Clo: grt:
House No, and Namo: 8 wate onfer are:
‘Street No. and Name: art /aceft