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Membership Application Form
Literacy Beneficiary Form
Thanks for registering with International literacy Mission! It's free and a simple process.
REGISTRATION APPLICATION FORM FOR COURSE
1. Registration Details / पंजीयन का विवरण
*
अनिवार्य फिल्डस (Mandatory fields)
Applicant's full name / आवेदक का पूरा नाम
*
Mr./श्री
Ms./सुश्री
( Full name as per the highest / latest qualification certificate or legal certificate )
Father's Name / पिता का नाम
*
Mr./श्री
( Full Name As Per Educational/Legal Certificate )
Mother's Name / माता का नाम
*
Mrs./श्रीमती
( Full Name As Per Educational/Legal Certificate )
Gender / लिंग
*
Male
Female
Date of Birth / जन्म दिनांक
*
(dd-Mon-yyyy)
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Month
1
2
3
4
5
6
7
8
9
10
11
12
/
Year
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
( As per high school certificate in 'dd-Mon-yyyy' format. i.e. '01-Jan-1990' )
Category / वर्ग
*
--Select One--
General / सामान्य
Scheduled Caste / अनुसूचित जाति
Scheduled Tribe / अनुसूचित जनजाति
Other Backward Class / अन्य पिछड़ा वर्ग
Economically Weaker Section / आर्थिक रूप से कमजोर वर्ग
Married Status / वैवाहिक स्थिति
*
--Select One--
Single / अविवाहित
Married / विवाहित
Divorced / तलाकशुदा
Widowed / विधवा / विधुर
2. Contact Details / संपर्क विवरण
Phone with STD Code/ दूरभाष एस टी डी कोड सहित
Mobile Number / मोबाइल नंबर
*
Email Address / ईमेल पता
(e.g.abc@yahoo.com)
3. Address Details / स्थायी पता विवरण
Address Line1/पता पंक्ति 1
*
Address Line2/पता पंक्ति 2
Block /ब्लाक
*
Panchat/Ward/पंचायत/वार्ड
*
Country
-Select-
Andorra
United Arab Emirates
Afghanistan
Antigua and Barbuda
Anguilla
Albania
Armenia
Angola
Antarctica
Argentina
American Samoa
Austria
Australia
Aruba
Aland Islands
Azerbaijan
Bosnia and Herzegovina
Barbados
Bangladesh
Belgium
Burkina Faso
Bulgaria
Bahrain
Burundi
Benin
Saint Barthelemy
Bermuda
Brunei
Bolivia
Bonaire, Saint Eustatius and Saba
Brazil
Bahamas
Bhutan
Bouvet Island
Botswana
Belarus
Belize
Canada
Cocos Islands
Democratic Republic of the Congo
Central African Republic
Republic of the Congo
Switzerland
Ivory Coast
Cook Islands
Chile
Cameroon
China
Colombia
Costa Rica
Cuba
Cape Verde
Curacao
Christmas Island
Cyprus
Czech Republic
Germany
Djibouti
Denmark
Dominica
Dominican Republic
Algeria
Ecuador
Estonia
Egypt
Western Sahara
Eritrea
Spain
Ethiopia
Finland
Fiji
Falkland Islands
Micronesia
Faroe Islands
France
Gabon
United Kingdom
Grenada
Georgia
French Guiana
Guernsey
Ghana
Gibraltar
Greenland
Gambia
Guinea
Guadeloupe
Equatorial Guinea
Greece
South Georgia and the South Sandwich Islands
Guatemala
Guam
Guinea-Bissau
Guyana
Hong Kong
Heard Island and McDonald Islands
Honduras
Croatia
Haiti
Hungary
Indonesia
Ireland
Israel
Isle of Man
India
British Indian Ocean Territory
Iraq
Iran
Iceland
Italy
Jersey
Jamaica
Jordan
Japan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Comoros
Saint Kitts and Nevis
North Korea
South Korea
Kosovo
Kuwait
Cayman Islands
Kazakhstan
Laos
Lebanon
Saint Lucia
Liechtenstein
Sri Lanka
Liberia
Lesotho
Lithuania
Luxembourg
Latvia
Libya
Morocco
Monaco
Moldova
Montenegro
Saint Martin
Madagascar
Marshall Islands
Macedonia
Mali
Myanmar
Mongolia
Macao
Northern Mariana Islands
Martinique
Mauritania
Montserrat
Malta
Mauritius
Maldives
Malawi
Mexico
Malaysia
Mozambique
Namibia
New Caledonia
Niger
Norfolk Island
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
Niue
New Zealand
Oman
Panama
Peru
French Polynesia
Papua New Guinea
Philippines
Pakistan
Poland
Saint Pierre and Miquelon
Pitcairn
Puerto Rico
Palestinian Territory
Portugal
Palau
Paraguay
Qatar
Reunion
Romania
Serbia
Russia
Rwanda
Saudi Arabia
Solomon Islands
Seychelles
Sudan
South Sudan
Sweden
Singapore
Saint Helena
Slovenia
Svalbard and Jan Mayen
Slovakia
Sierra Leone
San Marino
Senegal
Somalia
Suriname
Sao Tome and Principe
El Salvador
Sint Maarten
Syria
Swaziland
Turks and Caicos Islands
Chad
French Southern Territories
Togo
Thailand
Tajikistan
Tokelau
East Timor
Turkmenistan
Tunisia
Tonga
Turkey
Trinidad and Tobago
Tuvalu
Taiwan
Tanzania
Ukraine
Uganda
United States Minor Outlying Islands
United States
Uruguay
Uzbekistan
Vatican
Saint Vincent and the Grenadines
Venezuela
British Virgin Islands
U.S. Virgin Islands
Vietnam
Vanuatu
Wallis and Futuna
Samoa
Yemen
Mayotte
South Africa
Zambia
Zimbabwe
Serbia and Montenegro
Netherlands Antilles
State / राज्य
*
District / जिला
*
Pin Code / पिन कोड
*
4. Educational / Qualification Details / शैक्षिक / योग्यता का विवरण
SL.No./क्र.सं.
Qualification/ योग्यता
Board/University/ बोर्ड / विश्वविद्यालय
Passing Year/ पास वर्ष
Marks/ अंक
Percentage/ प्रतिशत
1.
High School/ उच्च विद्यालय
*
2.
Intermediate/ इंटरमीडिएट
*
3.
Graduation/ स्नातक
4.
Post Graduation/ पोस्ट ग्रेजुएशन
5.
BTC/ बीटीसी
6.
B.Ed/ch.,M.
7.
NTT/ एनटीटी
8.
Other/ अन्य
5. Identification Details / पहचान की सूचना
Aadhar Card Number (if) / आधार कार्ड संख्या (यदि हो तो)
Upload Photo / फोटो अपलोड करें
*
( JPG,JPEG,GIF,PNG image with size upto 50 KB )
6. Declaration / घोषणा (यदि हाँ तो बॉक्स (
) पर क्लिक (
) करें)
मैंए यह घोषणा करता/करती हूॅं कि साक्षर मित्र हेतु आनलाइन आवेदन फार्म में मेरे द्वारा वर्णित समस्त जानकारी मेरे ज्ञान और विश्वास से सत्य है। मैं जन जन साक्षर योजना के नियमो व विनियमों तथा मैं आर्गेनाईजेशन के सभी नियमों व निर्णयों से भी सहमत हूॅं और सदैव रहुॅगा/रहुॅगी। मुझे ज्ञात है कि योजना को उपर्युक्त उल्लिखित किसी भी प्रकार का कथन /विवरण असत्य पाये जाने पर नियुक्ति के पहले या बाद से मेरी पात्रता समाप्त समझी जाएगी इसके अतिरिक्त अन्य कोई कार्रवाई जो उचित समझी जाए ए अधिकार है। आगे मैं यह भी समझता हूॅं कि किसी भी प्रकार के कारणवश मेरी क्षति के लिए आर्गेनाईजेशन उत्तरदायी नहीं होगा।
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