Enrolment Form

‚¸š¸¸£ ›¸¸Ÿ¸¸¿ˆÅ›¸ / ¬¸¿©¸¸½š¸›¸ œ¸°¸

‚¸š¸¸£ ›¸¸Ÿ¸¸¿ˆÅ›¸ ¢›¸À©¸º¥ˆÅ ‡¨¸¿ ¬¨¸¾¢\ŽˆÅ í¾ — ›¸¸Ÿ¸¸¿ˆÅ›¸ ˆ½Å 96 ‹¸¿’¸½¿ ˆÅ½ ‚¿™£ ¬¸¿©¸¸½š¸›¸ ˆÅ£›¸¸ ž¸ú ¢›¸À©¸º¥ˆÅ í¾ — œ¸€¸ÁŸ¸Ä ¨¸ ‚¸š¸¸£ ›¸¸Ÿ¸¸¿ˆÅ›¸ ˆ½Å ¢¥¸‡ ˆÅ¸½ƒÄ ©¸º¥ˆÅ ›¸íì ¥¸Š¸÷¸¸ — ¬¸¿©¸¸½š¸›¸ ˆÅ£›¸½ ˆ½Å Ÿ¸¸Ÿ¸¥¸½ Ÿ¸½¿ ‚œ¸›¸¸ ƒÄ‚¸ƒÄ”ú, ›¸¸Ÿ¸ ÷¸˜¸¸ ˆ½Å¨¸¥¸ ¨¸íú œ¸€ú¥” ¬¸»¢\¸÷¸ ˆÅ£½¿ ¢]¸¬¸Ÿ¸½¿ ¬¸¿©¸¸½š¸›¸ ˆÅ£›¸½ ˆÅú ‚¸¨¸©¡¸ˆÅ÷¸¸ í¾ — ¬¸¿©¸¸½š¸›¸ ˆ½Å Ÿ¸¸Ÿ¸¥¸½ Ÿ¸½¿ ‚œ¸›¸¸ ƒÄ‚¸ƒÄ”ú ¬¸¿‰¡¸¸ ¡¸í¸¿ ™½¿ : — — — — — — — — —¢™¢™—Ÿ¸¸ — ¨¸«¸Ä — ‹¸¿’¸À¢Ÿ¸À¬¸¾À

ˆ¼Åœ¸¡¸¸ œ¸€¸ÁŸ¸Ä ž¸£÷¸½ ¬¸Ÿ¸¡¸ ¢œ¸Ž¥¸½ œ¸¼«“ œ¸£ ¢™‡ Š¸‡ ‚›¸º™½©¸¸½¿ ˆÅ¸ œ¸¸¥¸›¸ ˆÅ£½¿ — ˆ½Å¨¸¥¸ ¤¸”õ½ ‚®¸£¸½¿ Ÿ¸½¿ ž¸£½¿ — AADHAAR ENROLMENT / CORRECTION FORM

Aadhaar Enrolment is free and voluntary. Correction within 96 hours of enrolment is also free. No charges are applicable for Form and Aadhaar Enrolment. In case of Correction provide your EID, Name and only that field which needs Correction. In case of Correction provide your EID No here: | | | | | | | | | | | | | | | dd |mm| yyyy|hh: mm: ss|

Please follow the instructions overleaf while filling up the form. Use capital letters only. ›¸¸Ÿ¸¸¿ˆÅ›¸ ¬¸½ œ¸»¨¸Ä ‚¸ƒÄ”ú: ‡›¸œ¸ú‚¸£ £¬¸ú™/¢’›¸ ¬¸¿‰¡¸¸: 2 Pre-Enrolment ID: NPR Receipt/TIN Number: 3 œ¸»£¸ ›¸¸Ÿ¸ : Full Name: ¢¥¸¿Š¸ : œ¸º²Å«¸ ( ) ç¸ú ( ) ‚›¡¸ () ‚¸¡¸º : ¨¸«¸Ä/ ¡¸¸ ]¸›Ÿ¸ ¢÷¸¢˜¸ / :—¢™¢™—Ÿ¸¸Ÿ¸¸—¨¸«¸Ä ¬¸÷¡¸¸¢œ¸÷¸ ‹¸¸½¢«¸÷¸ / 4 5 Gender : Male ( ) Female ( ) Transgender ( ) Age: Yrs/ OR Date of Birth/ :|DD |MM |YYYY| Declared Verified / 6 œ¸÷¸¸ : ׸£¸ ( ) œ¸º°¸ú ( ) œ¸º°¸ ( ) œ¸÷›¸ú ( ) œ¸¢÷¸ ( ) ›¸¸Ÿ¸ / : Address: C/o ( ) D/o ( ) S/o ( ) W/o ( ) H/o ( ) NAME / : Ÿ¸ˆÅ¸›¸ ›¸¿0/¢¤¸¢¥”¿Š¸/‚œ¸¸’ÄŸ¸½¿’ : Š¸¥¸ú/Ÿ¸¸Š¸Ä/¥¸½›¸/: House No/ Bldg./Apt : Street/Road/Lane: ›¸]¸™úˆÅú œ¸í\¸¸›¸ ¬˜¸¥¸ (¥¸ÿ”Ÿ¸¸ˆÄÅ): ®¸½°¸/ƒ¥¸¸ˆÅ¸ /¬¸¾Æ’£ : Landmark : Area/locality/sector : Š¸¸¿¨¸/©¸í£/›¸Š¸£ : ”¸ˆÅ‹¸£ : Village/Town/City : Post Office: ¢]¸¥¸¸ : „œ¸-¢]¸¥¸¸ : £¸]¡¸ : District : Sub-District: State : ƒÄ Ÿ¸½¥¸ : Ÿ¸¸½¤¸¸ƒ¥¸ ›¸¿¤¸£ ¢œ¸›¸ ˆÅ¸½” — — — — — — — E Mail: Mobile No | | | | | | | | | | | PIN CODE | | | | | | | 7 ƒ›¸ˆÅ¸ ¢¨¸¨¸£µ¸ : ¢œ¸÷¸¸ ( ) Ÿ¸¸÷¸¸ ( ) ‚¢ž¸ž¸¸¨¸ˆÅ ( ) œ¸¢÷¸ ( ) œ¸÷›¸ú ( ) 5 ¨¸«¸Ä ¬¸½ ˆÅŸ¸ ‚¸¡¸º ˆ½Å ¤¸\\¸¸½¿ ˆ½Å ¢¥¸‡ ¢œ¸÷¸¸/Ÿ¸¸÷¸¸/‚¢ž¸ž¸¸¨¸ˆÅ ˆÅ¸ ¢¨¸¨¸£µ¸ ‚¢›¸¨¸¸¡¸Ä í¾ — ¨¸¡¸¬ˆÅ ¡¸¢™ ¡¸í ¬¸»\¸›¸¸ ›¸íì ™½ ¬¸ˆÅ÷¸½ / ™½›¸¸ ›¸íì \¸¸í÷¸½ ÷¸¸½ ‡½¬¸¸ ˆÅ£ ¬¸ˆÅ÷¸½ íÿ — Details of: Father ( ) Mother ( ) Guardian ( ) Husband ( ) Wife ( ) For children below 5 years Father/Mother/Guardian’s details are mandatory. Adults can opt to not 1

specify this information, if they cannot/do not want to disclose.

›¸¸Ÿ¸ : Name : ƒÄ‚¸ƒÄ”ú/ ‚¸š¸¸£ ¬¸¿0 .: — — — — — — — — — — — — — — — — — ¢™¢™—Ÿ¸¸Ÿ¸¸—¨¸¨¸— ‹¸¿‹¸¿:¢Ÿ¸¢Ÿ¸À¬¸¾¬¸¾— EID/ Aadhaar No.: | | | | | | | | | | | | | | | dd |mm| yyyy|hh: mm: ss| 8 Ÿ¸º^¸½ ˆÅ¸½ƒÄ ‚¸œ¸¢î¸ ›¸íì í¸½Š¸ú ¡¸¢™ ž¸¸£÷¸ú¡¸ ¢¨¸¢©¸«’ œ¸í\¸¸›¸ œÏ¸¢š¸ˆÅ£µ¸ Ÿ¸½£½ ׸£¸ „œ¸¥¸¤š¸ ˆÅ£¸ƒÄ Š¸ƒÄ ¬¸»\¸›¸¸ ˆÅ¥¡¸¸µ¸ˆÅ¸£ú ¬¸½¨¸¸‡¿ œÏ™¸›¸ ˆÅ£›¸½ ¨¸¸¥¸ú ‡½]¸¢›¬¸¡¸¸½¿ ˆÅ¸½ ™½÷¸¸ í¾ — í¸¿ ( ) ›¸íì ( ) I have no objection to the UIDAI sharing information provided by me to UIDAI with agencies engaged in delivery of welfare services. YES ( ) NO ( ) 9.¢›¸Ÿ›¸¢¥¸¢‰¸÷¸ Ÿ¸½¿ ¬¸½ ‡ˆÅ ˆÅ¸ \¸¡¸›¸ ˆÅ£½¿ (¨¸¾ˆÅ¢¥œ¸ˆÅ) (›¸¸Ÿ¸¸¿ˆÅ›¸ í¸½›¸½ ˆ½Å ¤¸¸™ ƒ¬¸ ”¸’¸ Ÿ¸½¿ œ¸¢£¨¸÷¸Ä›¸ ›¸íì ¢ˆÅ¡¸¸ ]¸¸ ¬¸ˆÅ÷¸¸)  Ÿ¸ÿ \¸¸í÷¸¸ (÷¸ú) í» ¢ˆÅ ž¸¸£÷¸ú¡¸ ¢¨¸¢©¸«’ œ¸í\¸¸›¸ œÏ¸¢š¸ˆÅ£µ¸ Ÿ¸½£ú ‚¸š¸¸£ ¬¸¿‰¡¸¸ ¬¸½ ]¸º”õ¸ ‡ˆÅ ›¸¡¸¸ ¤¸ÿˆÅ / ”¸ˆÅ‹¸£ ‰¸¸÷¸¸ ‰¸º¥¸¨¸¸ ™½ ‚¸¾£ ¡¸¢™ ƒ¬¸ˆ½Å ¢¥¸‡ ¨¸í Ÿ¸½£ú ]¸¸›¸ˆÅ¸£ú ‚›¡¸°¸ ™½÷¸¸ í¾ ÷¸¸½ Ÿ¸º^¸½ ˆÅ¸½ƒÄ ‚¸œ¸¢î¸ ›¸íì í¾—  Ÿ¸º^¸½ ‚œ¸›¸½ ¨¸÷¸ÄŸ¸¸›¸ ¤¸ÿˆÅ ‰¸¸÷¸½ ˆÅ¸½ ¡¸í¸¿ „œ¸¥¸¤š¸ ˆÅ£¸ƒÄ Š¸ƒÄ ‚¸š¸¸£ ¬¸¿‰¡¸¸ ¬¸½ ]¸¸½”õ›¸½ œ¸£ ˆÅ¸½ƒÄ ‚¸œ¸¢î¸ ›¸íì í¾ — £¸]¡¸ : ¤¸ÿˆÅ ˆÅ¸ ›¸¸Ÿ¸/©¸¸‰¸¸: ‚¸ƒÄ‡œ¸€‡¬¸¬¸ú ˆÅ¸½”: ‰¸¸÷¸¸ ¬¸¿‰¡¸¸: Select One of the Below (OPTIONAL) (This data cannot be Corrected after Enrolment)  I want UIDAI to facilitate opening of a new Bank/Post Office Account linked to my Aadhaar Number and have no objection to sharing my information for this purpose.  I have no objection to linking my present bank account provided here to my Aadhaar number. State : Bank Name/Branch: IFSC Code: Account No: ¬¸÷¡¸¸œ¸›¸ ˆÅ¸ œÏˆÅ¸£ : ™¬÷¸¸¨¸½]¸ ˆ½Å ‚¸š¸¸£ œ¸£ ( ) œ¸¢£\¸¡¸ˆÅ÷¸¸Ä ˆ½Å ‚¸š¸¸£ œ¸£ ( ) œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ( ) „œ¸¡¸ºÄÆ÷¸ Ÿ¸½¿ ¬¸½ ˆÅ¸½ƒÄ ‡ˆÅ \¸º›¸½¿ — ¡¸¢™ ‚¸œ¸ˆ½Å œ¸¸¬¸ œ¸í\¸¸›¸ ‚¸¾£ /¡¸¸ œ¸÷¸½ ˆÅ¸ ™¬÷¸¸¨¸½]¸ú œÏŸ¸¸µ¸ ›¸íì í¾ ÷¸ž¸ú œ¸¢£\¸¡¸ˆÅ÷¸¸Ä ¡¸¸ œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆÅ¸ \¸¡¸›¸ ˆÅ£½¿ — ¡¸¢™ ¬¸÷¡¸¸œ¸›¸ ™¬÷¸¸¨¸½]¸ œ¸£ ‚¸š¸¸¢£÷¸ í¾ ÷¸¸½ œ¸¢£\¸¡¸ˆÅ÷¸¸Ä ‚¸¾£ œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆÅ¸ ¢¨¸¨¸£µ¸ ‚œ¸½¢®¸÷¸ ›¸íì í¾ — Verification Type : Document Based ( ) Introducer Based ( ) Head of Family ( ) Select only one of the above. Select Introducer or Head of Family only if you do not possess any documentary proof of identity and/or address. Introducer and Head of Family details are not required in case of Document based Verification. 10 ™¬÷¸¸¨¸½]¸ œ¸£ ‚¸š¸¸¢£÷¸ í½÷¸º (œÏ¬÷¸º÷¸ ¢ˆÅ‡ Š¸‡ ™¬÷¸¸¨¸½]¸¸½¿ ˆÅ¸ ›¸¸Ÿ¸ ¢¥¸‰¸½¿—) For Document Based (Write Names of the documents produced.)

ˆÅ. œ¸í\¸¸›¸ ˆÅ¸ œÏŸ¸¸µ¸ a. POI Š¸. ]¸›Ÿ¸ ¢÷¸¢˜¸ : c. DOB :

‰¸. œ¸÷¸½ ˆÅ¸ œÏŸ¸¸µ¸ b. POA ‹¸. ¢›¸¨¸¸¬¸ ¬˜¸¸›¸ ˆÅ¸ œÏŸ¸¸µ¸ : d. POR:

(¬¸÷¡¸¸¢œ¸÷¸ ]¸›Ÿ¸ ¢÷¸¢˜¸ ˆ½Å Ÿ¸¸Ÿ¸¥¸½ Ÿ¸½¿ ‚¢›¸¨¸¸¡¸Ä) ( (Mandatory in case of Verified Date of Birth) (

11

) )

œ¸¢£\¸¡¸ˆÅ÷¸¸Ä œ¸£ ‚¸š¸¸¢£÷¸ í½÷¸º ‚¸š¸¸£ ¬¸¿0 — — — — — — — — — — —

- œ¸¢£\¸¡¸ˆÅ÷¸¸Ä ˆÅú

For Introducer Based Aadhaar No. | | | | | | | | | | | | |

– Introducer’s

œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ œ¸£ ‚¸š¸¸¢£÷¸ í½÷¸º - ¢¨¸¨¸£µ¸ : ¢œ¸÷¸¸ ( ) Ÿ¸¸÷¸¸ ( ) ‚¢ž¸ž¸¸¨¸ˆÅ ( ) œ¸¢÷¸ ( )

œ¸÷›¸ú () œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆÅú ƒÄ‚¸ƒÄ”ú/‚¸š¸¸£ ¬¸¿0: — — — — — — — — — ¢™¢™ —Ÿ¸¸Ÿ¸¸—¨¸¨¸— ‹¸‹¸À¢Ÿ¸¢Ÿ¸À¬¸¾.¬¸¾. For HoF Based - Details of : Father ( ) Mother ( ) Guardian ( ) Husband ( ) Wife ( ) HoF’s EId/Aadhaar No.: | | | | | | | | | | | | | | | dd |mm| yyyy|hh: mm: ss|

Ÿ¸ÿ ‡÷¸™×¸£¸ œ¸º¢«’ ˆÅ£÷¸¸ (÷¸ú) í» ¢ˆÅ ......................... ˆÅú œ¸í\¸¸›¸ ÷¸˜¸¸ œ¸÷¸¸ ¬¸÷¡¸ ‚¸¾£ ¬¸íú í¾ — œ¸¢£\¸¡¸ˆÅ÷¸¸Ä /œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆÅ¸ ›¸¸Ÿ¸: œ¸¢£\¸¡¸ˆÅ÷¸¸Ä/œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆ½Å í¬÷¸¸®¸£ I hereby confirm the identity and address of ______________________________as being true, correct and accurate. Introducer/HoF’s Name: Signature of Introducer/HOF ˆ½Å¨¸¸ƒÄ‚¸£ + ¬¸»\¸›¸¸ /KYR+ Information 112.

13.

‡¥¸œ¸ú]¸ú ˆ¿Åœ¸›¸ú / LPG Company

‡¥¸œ¸ú]¸ú Š¸¾¬¸ ˆÅ›¸¾Æ©¸›¸/LPG

¢¨¸÷¸£ˆÅ ˆÅ¸ ›¸¸Ÿ¸ /

GAS connection

Name of Distributor

£¸©¸›¸ ˆÅ¸”Ä / Ration Card

‡‡¨¸¸ƒÄ/¤¸úœ¸ú‡¥¸/‡œ¸ú‡¥¸/

ˆÅ¸”Ä ¬¸¿0/

AAY/BPL/APL

Card No.

¤¥¸» ˆÅ¸”Ä / Blue Card

ŠÏ¸íˆÅ ¬¸¿0 / Customer No.

œ¸¢£¨¸¸£ ˆ½Å ¬¸™¬¡¸¸½¿ ˆÅú ¬¸¿0 /No. of

ˆÅ¸”Ä ¬¸¿0/ Card No.

family members

License no.

œ¸¢£¨¸¸£ ˆ½Å ¬¸™¬¡¸¸½¿ ˆÅú ¬¸¿0 /No. of

‡œ¸€œ¸ú‡¬¸ ¥¸¸ƒ¬¸½¿¬¸ œ¸¢£¨¸¸£ ˆÅ¸ Ÿ¸º¢‰¸¡¸¸ / Head ¬¸¿0/FPS of the family

family members

14.

œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆÅ¸ ›¸¸Ÿ¸¸¿ˆÅ›¸ / ¡¸»‚¸ƒÄ”ú / Enrolment/UID of Head Of the family

15.

”︃¢¨¸¿Š¸ ¥¸¸ƒ¬¸½¿¬¸/ Driving

‡œ¸€œ¸ú‡¬¸ ¥¸¸ƒ¬¸½¿¬¸ œ¸¢£¨¸¸£ ˆÅ¸ Ÿ¸º¢‰¸¡¸¸ / Head ¬¸¿0/FPS of the family

License no.

œ¸¢£¨¸¸£ ˆ½Å Ÿ¸º¢‰¸¡¸¸ ˆ½Å ¬¸¸˜¸ ¢£©÷¸¸/Relation with head of the family

¥¸¸ƒ¬¸½¿¬¸ ¬¸¿0/License No.

License

]¸¸£úˆÅ÷¸¸Ä œÏ¸¢š¸ˆÅ¸£ú/ Issuing

]¸¸£ú ˆÅ£›¸½ ˆÅú ÷¸¸£ú‰¸/Date of Issue

Authority

16.

©¸ç¸ ¥¸¸ƒ¬¸½¿¬¸/Arms License

¥¸¸ƒ¬¸½¿¬¸ ¬¸¿0/ License No.

]¸¸£úˆÅ÷¸¸Ä œÏ¸¢š¸ˆÅ¸£ú/Issuing

17.

œ¸½¿©¸›¸ / Pensions

œ¸ú‡¥¸‡ ¬¸¿0/ PLA No.

]¸¸£úˆÅ÷¸¸Ä œÏ¸¢š¸ˆÅ¸£ú (¢]¸¥¸¸)/Issuing authority(District)

]¸¸£ú ˆÅ£›¸½ ˆÅú ÷¸¸£ú‰¸/Date of Issue

Authority

¨¸¾ˆÅ¢¥œ¸ˆÅ / Optional 18. Ÿ¸÷¸™¸÷¸¸ œ¸í\¸¸›¸ œ¸°¸ ¬¸¿0 /Voter Card No. 19. œ¸¾›¸ ¬¸¿0 / PAN No. ¬¸íŸ¸¢÷¸ Consent Ÿ¸ÿ œ¸º¢«’ ˆÅ£÷¸ ¸ (÷¸ú) í» ¢ˆÅ ž¸¸£÷¸ú¡¸ ¢¨¸¢©¸«’ ¬¸»\¸›¸¸ œÏ¸¢š¸ˆÅ£µ¸ ˆÅ¸½ Ÿ¸½£½ ׸£¸ „œ¸¥¸¤š¸ ˆÅ£¸ƒÄ Š¸ƒÄ ¬¸»\¸›¸¸ (¤¸¸¡¸¸½¢Ÿ¸¢’ïˆÅ ¬¸¢í÷¸) ‚¸¾£ ¡¸í¸¿ ™ú Š¸ƒÄ ¬¸»\¸›¸¸ Ÿ¸½£ú ‚œ¸›¸ú í¾ ‚¸¾£ ¬¸÷¡¸, ¬¸íú ‚¸¾£ „¢\¸÷¸ í¾— I confirm that information (including biometrics) provided by me to the UIDAI and the information contained herein is my own and is true, correct and accurate. ‚¸¨¸½™ˆÅ ˆ½Å í¬÷¸¸®¸£/‚¿Š¸»“½ ˆÅ¸ ¢›¸©¸¸›¸

Applicant’s signature/Thumbprint ¬¸÷¡¸¸œ¸›¸ˆÅ÷¸¸Ä ˆÅú Ÿ¸ºí£ ¨¸ í¬÷¸¸®¸£

Verifier’s Stamp and Signature (¡¸¢™ Ÿ¸ºí£ „œ¸¥¸¤š¸ ›¸ í¸½ ÷¸¸½ ¬¸÷¡¸¸œ¸›¸ˆÅ÷¸¸Ä ‚œ¸›¸¸ ›¸¸Ÿ¸ ‚¨¸©¡¸ ¢¥¸‰¸½¿) (Verifiers

must put his/ her, Name if stamp not available)

›¸¸Ÿ¸¸¿ˆÅ›¸ ‡]¸½¿¬¸ú ׸£¸ ž¸£¸ ]¸¸‡ —

›¸¸Ÿ¸¸¿ˆÅ›¸ ˆÅú ÷¸¸£ú‰¸ ¨¸ ¬¸Ÿ¸¡¸ :

To be filled by Enrolment Agency.

Date and time of Enrolment: