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Self Declaration Form
Name
*
Age
*
Gender
*
select Gender
Male
Female
Mobile Number
*
Alternate Mobile Number
Email Id
*
Occupation
*
Address & house no
*
Building / Apartment
*
Area
*
City
*
Camp
*
select camp
Camp 1
Camp 2
Camp 3
Camp 4
Camp 5
Other Camp
Ward No
*
select Ward
Ward 1
Ward 2
Ward 3
Ward 4
Pincode
*
Test Done ?
*
select option
Yes
No
Upload Result
* (Upload jpg, jpeg, png, gif file)
COVID - 19 Test Date
*
COVID - 19 Report Date
*
Care Taker Details
Care Taker Name
*
Care Taker Age
Care Taker Gender
select Gender
Male
Female
Care Taker Mobile
*
Care Taker Address
Upload Self Declaration Form
* (Upload jpg, jpeg, png, gif file)
Download Self Declaration Form
Doctor Name
*
Doctor Contact Number
*
Clinic / Hospital Address
*
Doctor Declartion upload
* (Upload jpg, jpeg, png, gif file)
Terms & Conditions
as per minister of H & F welfare , GOI dated 2nd july 2020