jktLFkku&ljdkj

lwpuk izkS|ksfxdh vkSj lapkj foHkkx

Hkkjrh; fof'k"B igpku izkf/kdj.k
Date (fnukad) :

Aadhaar Enrolment/Correction Form ( vk/kkj ukekadu@'kqf) izi= )

_ _ _ _ /_ _ _ _ /_ _ _ _ _ _ _

In Case of correction provide your EID No. here

('kq
'kqf) gsrq viuk bZ-vkbZ-Mh- la[;k fy[ksa )

|DD / MM / YYYY

(1) Full Name (iwjk uke)*

First Name (uke)

(2) Gender (fyax)*

Male(iq:"k)

(3) Age (vk;q)*

Yrs or

Middle name (e/; uke)

|hh:mm:ss

Last name (miuke)

Transgender(vU;)

Female(L=h)

Date Of Birth * (tUe frfFk)*

Document Based nLrkost ds vk/kkj ij

(4) Verification Type

FREE COPY (fu%kqYd izfr)

Pre-Enrolment ID : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Head of Family Based ifjokj ds eqf[k;k ds vk/kkj ij

Write name of the document produced in Sr.No.15 . Refer back side of this form for list of valid documents izLrqr nLrkostks ds uke dze la[;k 15 esa fy[ksaA oS/k nLrkostksa dh lwph ds fy,
QkeZ ds ihNs ns[ksa

(5) HoF Name (ifjokj

ifjokj ds eqf[k;k
dk uke)
uke

Father (firk)/

Mother (ekrk)/

Husband(ifr )/

Wife (ifRu )/

Guardian (vfHkHkkod)

(Name of Father/Mother/Guardian is must for children below 5 years)*

EID / UID No.

(5 o"kZ ls de mez ds cPpksa ds fy;s firk@ekrk@vfHkHkkod dk uke vfuok;Z gS )*

(bZbZvkbZMh/;w
h ;w-vkbZ-Mh-u- )

(6) Residential Address * (vkoklh;

vkoklh; irk )

C/o

D/o

S/o

W/o

House No./Bldg./Apt.( edku uEcj@fcfYMx)

Street/Road/Lane (xyh @lM+d dk uke)
Land Mark (Fky&fpUg)
Colony Name (eksgYys dk uke)
Name of Village/City ( xkao/kgj dk uke )
Post Office Mkd[kkuk
District (ftyk)
State (jkT;)
Pin Code (fiu dksM uEcj)*

H/o

Tehsil (rglhy)

E-mailbZ&esy

(7) Phone with STD code /Mobile No. (Qks

Qksu ,lVhMh dksM ds lkFk@eksckbZy uEcj )
(8) NPR Receipt No./TIN No.(,u-ih-vkj- jlhn la[;k )
(9)

Name (uke)

Select one of the below, this data can not be corrected after enrolment (uhps
uhps fn;s fodYiksa ess ls fdlh ,d dk p;u djsaA ukekadu ds i'pkr ;g lwpuk cnyh ugha tk
ldsxhA )
a.
I want to link my existing bank/ post office account to UID number and I have no objection on this issue

(eSa vius orZeku cSad@Mkd?kj [kkrs dks ;w-vkbZ-Mh uEcj ls tksM+uk pkgrk gwa ,oa eq>s bles dksbZ vkifRr ugha gSA)
Name of Bank/Post Office (cSad@Mkd?kj dk uke)
Branch ('kk[kk)
Account Number ([kkrk la[;k)
IFSC Code for Bank Only (cSad ds fy, vkbZ,Q,llh dksM)

OR (;k
;k)
;k

(eka
ekaad&9.a
&9 esa mij nh xbZ lwpuk,a 'kwU; gksus ij gh fuEu izfof"V djsaw )

b.

I want the UIDAI to facilitate opening of new Bank/Post Office Account linked to my Aadhaar Number and have no objection to sharing my information for this purpose.

eSa ;w-vkbZ-Mh-,-vkbZ leFkZ cSad@iksLVvkWfQl [kkrk [kksyuk pkgrk gw rFkk bl lwpuk dk lk>kk djus esa eqZ>s dksbZ vkifRr ugh gSA

Data Collection for State Government (KYR +) (jkT;

jkT; ljdkj ds fy, MkVk laxzg.k (ds
dsokbvkj+ +))
(10) Name of

Father (firk)/

(11) Ration Card Type

Husband(ifr ) dk uke *

APL (,ih,y)/

BPL (chih,y)/

AAY (,,okbZ)/

State BPL (jkT; chih,y)/

Other (vU;)/

No Card (dkMZ ugha)

(jkku
jkku dkMZ dk izdkj )
Ration Card No. (jkku
jkku dkMZ la[;k )
Name of Head Of Family (ifjokj
ifjokj ds eqf[k;k dk uke )
Relation with Head of Family (ifjokj
ifjokj ds eqf[k;k ls lEcU/k )

(12) BPL List No. (chih,y

chih,y lwph ekad )

Year (o"kZ
o"kZ )

District (ftyk)

Do you want to transfer BPL incentive amount in the above given account details at Sr. No. -8.

D;k vki chih,y izksRlkgu jkf'k ij fn, x, ekaad&8 ds [kkrs esa gLrkarj.k djuk pkgrs gSA

if no, then provide the below information:

Yes (gka)

No(ugha)

;fn ugha rks d`Ik;k fuEufyf[kr lwpuk, nsa

Name of Account Holder ([kkrk /kkjd dk uke)

Account Number ([kkrk laa[;k)
Name of Bank / Post office (cSad@iksLV vkWfQl dk uke)
Branch ('kk[kk)
Relationship with account holder

IFSC Code for Bank Only (cSad ds fy, vkbZ,Q,llh dksM)

Father (firk)/

Mother (ekrk)/

Spouse (ifr / ifRu)/

Other (vU;)

(13) MGNREGA Job Card No (egkujsxk tksc dkMZ la[;k)

(14) Pension Payment Order No. (isUku Hkqxrku vknsk ekad)

Declaration (?kks
?kks"k.kk)
k.kk
I have previously not applied for UID number. The information provided by me is true to the best of my knowledge. I am aware
that the information provided by me for securing UID number shall be shared and used for authenticating my identity and
government may share and use this information for delivery of various services from time to time.
eSaus iwoZ esa ;w-vkbZ-Mh- uEcj ds fy;s vkosnu ugha fd;k gSaA ;g lwpuk esjh tkudkjh ds vuqlkj lR; gSAeq>s Kkr gS fd esjs }kjk ;wvkbZMh uEcj izkIr djus ds fy;s
nh xbZ lwpuk esjh igpku dks izekkf.kd djus ds fy;s iz;ksx dh tk;sxh ,oa ljdkj bl lwpuk dk mi;ksx le; le; ij fofHkUu lsok,sa miyC/k djkus ds fy,
fd;k tk ldsxkA

(15) SN
1
2
3
4

Applicant Signature / Thumb Impression

(vkos
vkosnd ds gLrk{kj@vaxwBs dk fukku )

Verified Documents (lR;kfir nLrkost) :

To be Filled by verifier (lR;kid

lR;kid }kjk Hkjk tkosa )

POI igpku izek.k i=

Above information is true to best of my knowledge (mijksDRk lwpuk esjh tkudkjh ds vuqlkj lR; gSA )

POA fuokl izek.k i=

Verifier Name (lR;kid dk uke):

DOB tUe frfFk izek.k i=

Verifier Code (lR;kid dk dksM):

POR lEcU/k izek.k i=

Signature (gLrk{kj):

*Mandatory Information (vfuok;Z

vfuok;Z lwpuk )

Date (fnukad):

Name of enrolment agency

vkosndks ds fy, fn'kk&funsZ'k

1.
2.

;g izi= vkosnd vk/kkj ukekadu vFkok ukekadu esa lakks/ku gsrq mi;ksx esa fy;k tk ldrk gSA lakks/ku gsrq vkosnd dks iwoZ esa nh xbZ
ukekadu ikorh ij vafdr bZ-vkbZ-Mh- fy[kuk vfuok;Z gksxkA
vkosndks dh igpku ds fy, Lohdk;Z nLrkost fuEuizdkj gS A
ikliksVZ
jk'ku@ihMh,l QksVks dkMZ
okgu pkyd igpku i=
QksVks cSad ,Vh,e dkMZ
ljdkj@ih-,l-;w }kjk tkjh
igpku i= e; QksVks
Lora=rk lsukuh QksVks dkMZ
fdlku QksVks ikl cqd

3.
4.

5.
6.

8.

Mkd foHkkx }kjk tkjh fd;k x;k QksVks lfgr igpku

i=
ysVjgsM ij xzqi , jktif=r vf/kdkjh }kjk tkjh
QksVks igpku izek.k i=
ekU;rk izkIr 'kSf{kd laLFkku }kjk tkjh fd, x;s QksVks
igpku i=
vleFkZrk izek.k&i=
ukxfjdrk izek.k i=

igpku ds fy, mijksDr lwph esa ls izLrqr nLrkostks esa vkosnd dk uke ftl izdkj ls vafdr gks mlh izdkj bl dkye esa vafdr fd;k
tkos A
vkosnd iq:"k@L=h@vU; ds fodYi ds lEcU/k ls lECfU/kr ckWDl esa
dk fpUg yxkos A
vkosnd tUe frfFk ds fy, mijksDr lwph esa ls izLrqr nLrkost esa ls tUefrfFk dks Li"V :i ls lEcfU/kr dkWye ess fnu] eghuk o o"kZ esa
vafdr djs A nLrkostksa ds vHkko esa vkosnd viuh vuqekfur vk;q ntZ djs A tUe frfFk gsrq Lohdk;Z nLrkost fuEu izdkj gS &
tUe izek.k i=
ikliksVZ ek/;fed fo|kky;10oha dk izek.k i=
ysVjgsM ij xzqi ^,* jktif=r vf/kdkjh }kjk tkjh tUe izek.k i=
vkosnd viuk lR;kiu nLrkostksa vFkok ifjokj ds eqf[k;k ds vk/kkj ij dj ldrk gSA ;fn lR;kiu nLrkostksa ds vk/kkj ij gS rks
vkosnd dkss nLrkostksa dh lwph esa nLrkostksa ds uke vafdr djuk gksxkA lR;kiu ifjokj ds eqf[k;k ds vk/kkj ij gksus dh fLFkfr esa eqf[k;k
dh lwpuk dze la[;k 7 esa vafdr djuk vfuok;Z gksxkA
ifjokj ds eqf[k;k ls laca/k crkus ds fy, Lohdk;Z nLrkostksa dh lwph fuEu izdkj gS
jk'ku@ihMh,l dkMZ
vkehZ dSUVhu dkMZ
dsUnz vFkok jkT; ljdkj }kjk
tkjh ifjokj ik=rk nLrkost

7.

isudkMZ
ernkrk igpku i=
ujsxk tksc dkMZ
'kL= ykblsal
isa'kuj QksVks dkMZ
QksVks sfMV dkMZ
lhth,p,l@,lh,p,l QksVks dkMZ
tkfr izek.k i= e; QksVks

ujsxk tksc dkMZ

isa'kuj dkMZ
tUe izek.k i=

lhth,p,l@,lh,p,l dkMZ
ikliksVZ

5 o"kZ ls de mez ds cPpksa ds fy, muds firk@ekrk@vfHkHkkod dk uke o ukekadu la[;k vFkok vk/kkj uEcj vfuok;Z :i ls fy[kk
tkuk gS A vU; vkosnd ;Fkk lEHko ;g izfo"Bh djs] ;|fi muds fy, ;g lwpuk vafdr djuk oSdfYid gS A vkosnd ;fn fookfgr efgyk
gS rks ;Fkk laHko og vius ifr dk uke vafdr djs A
vkoklh; irs ds fy, Lohdk;Z nLrkostksa dh lwph bl izdkj gS &

ikliksVZ
cpr [kkrk fooj.k@iklcqd
jk'ku dkMZ
Mkbfoax ykblsal
ljdkj@ih-,l-;w }kjk tkjh
igpku i= e; QksVks
chek ikWfylh
fctyh@ikuh@xSl@VsyhQksu dk fcy
3 eghus ls T;knk iqjkuk u gks
sfMV dkMZ LVsVesaV 3 eghus ls
T;knk iqjkuk u gks
laifk dj jlhn 3 eghus ls
T;knk iqjkuk u gks

cSad LVsVesaV@iklcqd
ernkrk igpku i=
ujsxk tksc dkMZ
fdlku iklcqd
okgu iath;u izek.k i=
iSa'ku dkMZ
'kL= j[kus dk ykblsal
Lora=rk lsukuh QksVks izek.k i=
jkT; ljdkj }kjk tkjh fd;s x;s
tkfr@ewyfuokl izek.k i=
vk;dj fu/kkZj.k vkns'k
ljiap }kjk tkjh fuokl izek.k i=
xzkeh.k {ks=ksa ds fy,

iathr daiuh }kjk tkjh fd;s x;s QksVks ds

lkFk izek.k i=
iathr fch@yht@fdjk, ij fy;s x;s
edku dk djkjukek
lhth,p,l@lh,p,l QksVks dkMZ
ekU;rk izkIr cSad ds ysVj gSM ij QksVks
lfgr gLrk{kfjr i=
Mkd[kkus }kjk QksVks lfgr tkjh fd;k x;k
irk igpku i=
lkaln@fo/kk;d ;k jktif=r vf/kdkjh }kjk
ysVjgsM ij QksVks lfgr tkjh fd;s x;s izek.k
i=

vkosnd mijksDr lwph esa ls izLrqr nLrkost esa fn, x, irs dks fof/kor rjhds ls lEcfU/kr iafDr;ksa esa Hkjs A vkosnd ;g lqfuf'pr dj ys
fd fiu dksM la[;k Li"V :i ls vafdr dj nh x;h gS A
9. vkosnd laxr dksM STD dksM lfgr nwjHkk"k la[;k ;k eksckby uEcj Li"V :i ls nl vadks eas vafdr djs A
10. vkosnd tux.kuk ds le; jk"Vh; tula[;k jftLVj NPR ds fy, yh x tkudkjh ds le; tkjh dh x jlhn la[;k Li"V :i ls
vafdr djs A
11. vkosnd ;fn vius orZeku cSad@Mkd?kj [kkrs dks ;w-vk-Mh- uEcj ls tksMus ds fy, lger gks rks lEcfU/kr ckWDl esa
dk fpUg
yxkos ,oa lkFk gh lEcfU/kr cSad@Mkd?kj dk uke] 'kk[kk] [kkrk la[;k dks Li"V :Ik ls vafdr djsa A
vkosnd ds ikl mijksDr cSad ;k Mkd?kj [kkrk ugha gksus dh n'kk esa u;k [kkrk [kksyus gsrq lger gksus ij lEcfU/kr ckWDl esa
dk
fpUg yxkos A
12. vkosnd firk@ ifr dk uke vfuok;Z :Ik ls vafdr djs Aa
13. vkosnd }kjk ftl izdkj dk jk'ku dkMZ izLrqr fd;k x;k gks mlls lEcfU/kr ckWDl esa
dk fpUg yxkos ,oa jk'kudkMZ ekad]
ifjokj ds eqf[k;k dk uke ftlds uke ij jk'ku dkMZ cuk;k x;k gks ,oa ef[k;k ls lEcU/k dk fooj.k Li"V :i ls vafdr djs A
vkosnd ;fn ch-ih-,y- Js.kh esa vkrk gS rks ch-ih-,y- ekad Li"V :i ls vafdr djs A ;fn vkosnd ch-ih-,y- Js.kh esa ukekadu ds fy, nh
tkus okyh izksRlkgu jkf'k ekad&8 esa fn;s x, cSad@Mkd?kj ds [kkrs esa gLrkfUrfjr djokuk pkgrk gS rks lEcfU/kr ckWDl esa
dk
fpUg yxkos A vU;Fkk ftl Lo;a ;k lEcfU/kr O;fDr ds [kkrs esa tek djokuk pkgrk gS mlds [kkrs dh lHkh lwpuk,a nh tkos A
14. vkosnd vius ;k vius ifjokj dk chih,y lwph ekad Li"V :i ls vafdr djs A
15. ;fn vkosnd ds ikl egkujsxk tkWc dkMZ gS rks lEcfU/kr ckWDl esa
dk fpUg yxkos ,oa tkWc dkMZ u- Li"V :i ls vafdr djs A
16. vkosnd ;fn lkekftd lqj{kk ds rgr nh tkus okyh ias'ku tSls fo/kok] fodykax] o`)koLFkk bR;kfn ds vUrZxr dks isa'ku ysrk gS rks ml
isa'ku Hkqxrku vkns'k ekad dks Li"V :i ls vafdr djsa A
uksV %&
12345-

fuj{kj ukxfjdksa ds fy, ukekadu i= Hkjus dh ftEesnkjh lgk;rk dsUnz gsYi MsLd ds lapkyd dh gksxhA ukekadu i= Hkjus ds ckn
vkosnd dk vxwBk ;k fukkuh vfuok;Z gSA
ukekadu laLFkk }kjk lHkh izek.ki=ksa@nLrkostksa dh QksVksdkWih ij fu%kqYd dh tk,xhA
ukekadu i= ukekadu lLaFkk }kjk fu%kqYd miyC/k djok;k tk,xkA
lEiw.kZ vk/kkj ukekadu izf;k izR;sd Hkkjrh; fuoklh ds fy, fu%kqYd gSA
vkosnu izf;k esa fdlh Hkh izdkj dh fkdk;r gksus ij vkosnd ukekadu laLFkk dk fooj.k tSls fd laLFkk dk uke] LFkku] vkWijsVj dk uke
;g lHkh lwpuk,a ukekadu laLFkk }kjk cSuj cukdj ukekadu dsUnz ds eq[; }kjk ij yxk;k tkuk vfuok;Z gSA) ;w-vkbZ-Mh- izdkss"B ftyk
eq[;ky; esa nsosaA