EMPLOYEE ENROLLMENT APPLICATION
PERSONAL DETAILS
Employee ID : Aadhar ID/Enrollment ID Applicant Type :
0854113 : XXXXXXXXXXXX Employee
Name : THALLA
Date Of Birth
MOHAN Gender : Male
: 04/06/1997
NARASIMHULU
Date of
Marital Status :
Community: BC Community: BC Joining :
Unmarried
21/11/2019
Disability Percent: -
Disabled: N Disability: -NA-
NA-
ADDRESS DETAILS
Residential Address:
Street No: GAMALLA STREET
House No: 8-11 State: ANDHRA PRADESH
VERUBOTLA PALLI
District: SRI
Mandal/Municipality: KALUVOYA Location:
POTTISRIRAMULU
-R KANUPURUPALLE
NELLORE
Mobile Number:
Email: mohanthalla9@gmail.com
8374567482
Office Address:
House No: CHEEPINAPI
Street No: CHEEPINAPI State: ANDHRA PRADESH
VILLAGE SECRETARIAT
District: SRI
Location: ANDHRA
POTTISRIRAMULU Mandal/Municipality:
PRADESH
NELLORE
Mobile
Email: mohanthalla9@gmail.com
Number: 8374567482
IDENTIFICATION DETAILS
Ration Card No: -NA-
Identification Marks 1: A MOLE ON CHEST
Identification Marks 2: A MOLE NEAR RIGHT EYEBROW
DECLARATION
I declare that
I have no objection in sharing Aadhar data of my family.
I am liable for disciplinary action for declaring ineligible family as dependents, and
I declare that the above information is true to best of my knowledge and submitting to
Dr. YSR Aarogyasri Health Care Trust for issue of Health cards under beneficiary. I am
liable for disciplinary action for declaring ineligible family member if any as
Dependents.
Place:
Date:
Signature of Employee
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