Agriculture - Registration

AGRI CLINIC AND AGRI BUSINESS CENTRE SCHEME
APPLICATION FORM

1. NAME OF THE CANDIDATE : *
2. NAME OF FATHER / SPOUSE :
3. DATE OF BIRTH(DD/MM/YYYY) : *
4. GENDER : *	Male Female
5. AADHAAR NUMBER : *

6. PERMANENT ADDRESS :
Village & Panchayat :
Block :
Taluk :
District :
State :
Pincode :

7. ADDRESS FOR CORRESPONDENCE :
8. EDUCATIONAL QUALIFICATION :
Name of Degree / Diploma / Certificate Course :
Board / Institute / University where studied :
University to which Affiliated :
Marks / Grade obtained :
Year of passing / completion :

9. CONTACT DETAILS
Telephone / Mobile : *
Email ID : *

10. EXPERIENCE
11. FAMILY BACKGROUND
Agriculture
Other than agriculture

12. AGRI-BUSINESS INTEREST
Nature of enterprises being planned to setup after the training
Experience in the enterprises being planned
Likely place of establishment of enterprises

13. APTITUDE FOR EXTENSION WORK WITH BRIEF DETAILS OF EXTENSION WORK DONE AND VISION FOR FUTURE IN SERVING FARMERS

14. BANK DETAILS
Bank Name
Branch
Account No.
IFSC Code
Upload your photo *
Educational Certificate
Attach Aadhaar Card *
Bank Passbook