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Personal Information
Additional Details
Confirmation
Worker Name*
Date of Birth*
Age
Sex*
Select
Male
Female
Email
Phone Number*
Voter ID Number
Aadhaar Number*
Father Name*
Spouse Name (Leave blank if NA)
For card holders / registered workers
Registered Worker
Yes
Registration ID
Registration Date
State*
Select
Manipur
District*
Select
Bishnupur
Chandel
Churchandpur
Imphal East
Imphal West
Jiribam
Kakching
Kamjong
Kangpokpi
Noney
Pherzawl
Senapati
Tamenglong
Tengnoupal
Thoubal
Ukhrul
Constituency*
Select
Andro
Bishnupur
Chandel(ST)
Chingai(ST)
Churachandpur(ST)
Heingang
Heirok
Henglep(ST)
Hiyanglam
Jiribam
Kakching
Kangpokpi(GEN)
Karong(ST)
Keirao
Keishamthong
Khangabok
Khundrakpam
Khurai
Konthoujam
Kshetrigao
Kumbi
Lamlai
Lamsang
Langthabal
Lilong
Mao(ST)
Mayang Imphal
Moirang
Nambol
Naoriya Pakhanglakpa
Nungba(ST)
Oinam
Patsoi
Phungyar(ST)
Sagolband
Saikot(ST)
Saikul(ST)
Saitu(ST)
Sekmai(SC)
Singhat(ST)
Singjamei
Sugnoo
Tadubi(ST)
Tamei(ST)
Tamenglong(ST)
Tengnoupal(ST)
Thanga
Thangmeiband
Thanlon(ST)
Thongju
Thoubal
Tipaimukh(ST)
Ukhrul(ST)
Undefined
Uripok
Wabagai
Wangjing Tentha
Wangkhei
Wangkhem
Wangoi
Yaiskul
Address/ Village/ City/ Town*
Police Station*
Pin Code
Present Address*
Marital Status*
Select
Single
Married
Handicap/ Disable
Yes
Occupation
Select
Brick Work
Building Construction
Canal Construction
Carpentry
Culvert Work
Dam Construction
Electrician
Iron & Steel
Mason
Paint
Plumber
Road Work
Sweeper
Tiles Work
Name:
Date of Birth and Age:
(
)
Sex:
Email:
Phone:
Aadhaar No:
Voter ID No:
Father's Name:
Spouse's Name:
Permanent Address:
,
,
,
,
Present Address:
Constituency:
Marital Status:
Handicap:
Occupation:
I declare that the data provided by me is true to the best of my knowledge.