WeConnect Jan Seva Kendra

APPLICATION FORM for Individual

To PHOTO

The Officer in charge,

Citizencenter Technologies Private Limited

First Name ______

Middle Name ______

Surname ______

Date of Birth (DD/MM/YYYY): ______

Sex: M / F ______

Marital Status: ______

Sir,
I wish to apply for a“Weconnect Jan Seva Kendra”in the below mentioned location. My particulars are given below:
Address: / Village/Town:
PO:
Taluka:
Block:
District :
State:
PIN :
Father’s /
Husband’s
Name
Phone No. [R]______[M] ______
E mail id :
Period of Stay at current location (in Yrs)

1 | PageWeConnect Jan Seva Kendra(PEC)

Please furnish the following Important Information

Education: ______
Qualification : / Diploma / Professional Courses ______
Computer Skills : Basic / Intermediate / Advance ______[Specify]
Address Proof:Voters ID / Driving License / Passport / Ration Card / Aadhar Card
No. ______
References:
  1. Name:______Phone: ______
Address: ______
  1. Name: ______Phone: ______
Address: ______
Economical and Financial Indicators :
  1. Average Monthly Income [Rs.] ______Proof Available [Y/N]
  2. Profession : ______
  3. Bankers Name:______A/C No. ______
  4. Pan No : ______
  5. Fix Asset Details with Proof :
  6. Remarks ( Network Partner )
Proposed Citizen Center Details:
  1. Village / Location: ______
Taluka / Block: ______
District: ______
Pin Code: ______
State: ______
Population Covered within 5Kms: ______
  1. Property Status : [Own / Rented ]
  2. Shop Area in Sq. Ft : ______Landmark ______
  3. Property Address : ______
______
  1. Nearest Bank Branch : ______
  2. Availability of BSNL / Broadband : ______

Citizen Center Eligibility Criteria
  1. Preferably between the age group of 20-30:
  1. Qualification required 12th pass/ Graduate:
  1. Computer literate, possessing entrepreneurial skills:
  1. Should be able to arrange min. 250 sq.ft of space
  1. Should be the resident of area where the Citizen Centerwill be set up:

Documents Required for the Individual
ID Proof
Center Location Proof
Age Proof
Education Proof
Photograph / Aadhar Card / Pan Card / Driving License / Passport
7-12 Extract / Sale Deed / Leave and License Agreement / Electricity Bill / Property Tax Bill
Driving License / SSC certificate / School Leaving Certificate
Passing certificate of the 12th Class or above
4 passport size color
Infrastructure Requirements
  • Suitable Connectivity, Preferably Broadband
  • 1 Latest Technology PC with licensed software
  • 1 Table 4 ft.*2 ft.
  • Chairs- 5 no’s
  • Cupboard with Lock
  • Soft Board Blue Colored 2 ft.*5 ft.
  • Sign Board – 6 ft. * 4 ft. (Design will be provided)
  • 1 Full UID kit with Laptop/IRIS/Biometric/Printer Etc.
  • 1 PVC Printer

Signature of the Applicant –

Date –____/_____/______

  • All the Information given in this application is true and if any found wrong, I myself will be responsible for the same.

For Internal Use of CCTPL Officials Only:

  1. Importance of the proposed location:
  1. Special Remark if any:

Name of the Representative: ______

Signature of the Representative:______

Date: ____/_____/______

1 | PageWeConnect Jan Seva Kendra(PEC)