FOR AADHAAR ENROTME UP
lnstructions: All details to be filled in Block Letters
(To be volid for 3 months lrom dote ol issue)
To be printed on ploin A4 poper size; Not required to print on letter head;
lLTS J o €l o {-
Resident Non-Resident lndian (NRt) New Enrolment
I I--f uoar,. Request
Aadhaar Number:
(For update only) 2- a- 4ls t16 g €i q 4 qd
Full Name:
E ft R a T _S /l N rl n Y N U Mlt A p
i"J
cto:
House No./ Bldg./ Apt:
$treet/ Road/ Lane: *s l+ Y fr NI 4 L P ft R Z- _sh R1
Landmark:
B n L T I frlD E V r1* I n1 r L E
Area/ Locality/ Sectcr:
VBllage/ Town/ Citv:
k A -T H \^/ fr F;1+
Post Office:
k n T t-l \/ i?b ft I
District:
State:
PIN Code:
36 L hls o :;. ? M{e +-
Date of Birth:
C l o 5 I q q Z-
Signature of the Resident/
Thumb/ Finger lmpression
certifier
Name of the Certifier:
Designation:
o R
Office Address: 2 ? R r.J a al r olc A -t
t\ i.o
IU f\ D t( s o
Contact Number:
I hereby r.ertify above nrentioned details of the resrdent Checklist for Certifier
anci I am a..., (Tick appropriate box below)
I No overwriting I tssue date is fiiled f! Resident's signature ficertifier,s detairs
I Cazetted Officer - Group A I Resident's Ph6to is cross signed and cross sta mped (poper to phato or photo to poper)
I Vitiage panchayat Head or Mukhiya
I Gazetted Officer - Group B
W*rt MLA/ MLC/ Muncipat Councitor a
MuniciPal &
Councillor
! rer,sildat lt z Nikoi
f neaO of Recognized Educational tnstitution \\ No.
I Superintendent/ Warden / Matron/ t-tead of Institution
a
of Recognized shelter homes/ Orphanages
f rerooifi.e, Sitnature & Stamp ofthe Certifier
NOTE: This format is applicable for Pol documents at sl. Nos. 17, 20, 2r, 22, 3L & 32; poA docu ments at s t. Nos. 23, 24, 37,
3a, 44 & 45; poR documents at st. Nos. 13
& 14 DoB documents at sl' Nos. 4, 5, 14 & 15 of schedule ll of the Aadhaar (Enrolment and update) Regulations, 2016, as amended from time
to time.
