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Application for SamagRA Online KIOSK Allotment

Kindly check Pending Applications for Kiosk, if your application exists in this list then no need to apply. Click here for Pending Applications
First Name * Middle Name Last Name*
Gender*
Father/Husband Name* Date of Birth*
State* District*
Block/Tehsil*
Gram Panchayat*
Locality* City/Village*
Residential Address* Pincode* Email *
Phone No. Mobile No.*
PAN No.*
Aadhar Are you 10th pass ? * Residence Proof*
   Please tick if shop address is same as applicant's residence address
Shop/Office Name*
State* District*
Block/Tehsil*
Gram Panchayat*
Locality* City/Village*
Pincode*        
Phone No. Mobile No.*
Fax No.
Shop/Office Address*
Landmark close by*
Shop/Office Address Proof * Basic Nature of Business*
Internet Connection Type*
No. of Computer's* No. of Printer's* No. of Scanner's*
No. of Camera's * Bio-Metric Device*
Power Backup*
No. of Computer Operator's* Conversant in Typing & Reading*
  Account Holder Name Bank Name Account Type
Account No Branch IFSC Code
  Reference by Reference Code    
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