Are you looking for an easy way to connect with the people of your community? Are you looking for a way to provide valuable resources and information to your constituents? If so, then the E Mitra kiosk may be right for you! This comprehensive application form will help you determine if the kiosk is a good fit for your organization. Please take a few minutes to fill out the form and we will be in touch soon! Thank you for your interest in the E Mitra kiosk!
| Question | Answer |
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| Form Name | Application Form For E Mitra Kiosk |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | emitra near me, e mitra centre in ahmedabad, frnamn, emitra sex |
Application Form for
All fields are mendatory as mark *
Basic Details:-
Dist rict * |
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The latest |
LSP* |
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Kiosks Owner |
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Kiosk Owner Details:- |
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Kiosk Owner Type* |
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Individual |
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Company |
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Kiosk Owner Name* |
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Permanent Address* |
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Owner Phone Numbers*-
Owner |
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Mobile*
Kiosk Center Details:- |
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Kiosk Center Location* |
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Kiosk Center Name (English)* |
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Kiosk Contact (Hindi)* |
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Kiosk Contact Person's Name |
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Kiosk's Phone Numbers |
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Kiosk eMail ID* |
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Police Station (Thana) * |
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Kiosk Address (IF URBAN) * |
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Municipal Town*
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Urban |
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Rural |
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Mobile*
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Ward Number*
Kiosk Address (IF RURAL) *
Panchayat Samiti*
Gram Panchayat*
Village*
PIN Code*
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PIN Code*
Signature of LSP |
Signature of Kiosk Owner |
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Kiosk Bank a/c Details:- |
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A/C Number |
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IFSC Code |
Bank a/c Number |
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Bank Name |
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Branch Name |
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Account Holder Name |
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If this kiosk had already user ID on eMitra Portal please provide us:- |
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Kiosk ID |
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LSP Name |
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Level (Please define the Level of Kiosk if the kiosk having more than one level, mention all
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Level |
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Details (Name) |
Private |
IT Center |
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Location |
(Rajasthan Sampark / |
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Government Building) |
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District (Head Quarter) |
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Tehsil |
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Panchayat Samiti / Block |
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Gram Panchayat |
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Village |
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Check List of Enclosures:- |
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1. |
I.D. Proof / Address Proof * |
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2. |
Police Verification Report* |
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3. |
Educational Qualification* |
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4. |
Bank A/C Details |
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Above mention check List are checked are correct in my knowledge.
Signature Kiosk Owner |
Signature and Seal |
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LSP |
Date : |
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For Office Use –
Verified By DeGS with Seal