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e-SHRAM Application Form Template

This document contains an application for an e-SHRAM registration. It collects personal details such as name, date of birth, gender, addresses, bank account information, education level, income details, occupation skills, and nominee details from the applicant. The applicant is asked if they are a member of EPFO or ESIC. Their signature and that of the volunteer are required at the bottom.

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Madhavakumar Unnam
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2K views2 pages

e-SHRAM Application Form Template

This document contains an application for an e-SHRAM registration. It collects personal details such as name, date of birth, gender, addresses, bank account information, education level, income details, occupation skills, and nominee details from the applicant. The applicant is asked if they are a member of EPFO or ESIC. Their signature and that of the volunteer are required at the bottom.

Uploaded by

Madhavakumar Unnam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

e-SHRAM Application

Volunteer Name :_____________________ Cluster Number :_________

Aadhar Linked Mobile Number:___________________________________

Are you a Member of?

Employee’s Provident Fund Organization (EPFO): Yes/No

Employee’s State Insurance Corporation (ESIC): Yes/No

Applicant Name :____________________________________

Date of Birth (dd/mm/yy) :____________________________________

Gender : Male / Female

Address :____________________________________

____________________________________

____________________________________

Pincode :____________________________________

Your Aadhar Linked Bank :____________________________________

Bank Aadhar Seeding Status: Active / Inactive

Personal Information:
Mobile Number :_________________________________
Emergency Mobile Number:_________________________________
Email (optional) :_________________________________
Marital Status : Married/Unmarried
Father Name :________________________________
Caste :__________ Sub Caste:____________________
Blood Group (optional) :_________________________________

Nominee Details:
Nominee Name :_________________________________
Nominee Aadhar Number :_________________________________
Residential Address:
Home State :_____________________________________

Current Address:

House Number :_______________ Locality :_____________________

State :_______________________ District :_____________________

Sub District:__________________ Pin Code:____________________

Permanent Address:

House Number :_______________ Locality :_____________________

State :_______________________ District :_____________________

Sub District:__________________ Pin Code:____________________

Staying at Current Location :Yes/No

Migrant Worker : Yes/No

Education Qualifications: 1-5th/6th – SSC/Inter/Diploma/Degree/B Tech/PG/Others

Monthly Income Slab:1k-5k/6k-10k/11k-15k/16k-20k/21k +

Income Certificate Number :_______________________________________

Occupation Skills:
Primary Occupation :_____________________________________________

Working Experience in Primary Occupation:___________________________

Secondary Occupation :___________________________________________

How Did You Acquire Skills :_______________________________________

Skills to be Upgraded :___________________________________________

Bank Account Details:


Bank Account Number :__________________________________________

Account Holder Name :__________________________________________

IFSC Code :__________________________________________

Bank Name :__________________________________________

Branch Name :__________________________________________

Volunteer Signature Applicant Signature

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