Annexure VI
SF6.2A3: Candidate Application Form
(This will be uploaded on ERP system, till then this form will be used)
Ministry of Rural Development , Government of India
KRISHNA SAI EDUCATIONAL SOCIETY
Project number 52
State
Training Centre Name
Address of Training Centre
Nearest Police Station
Batch Number
Trade
Registration number
Date of Registration
Training duration
To be filled by candidate:
A. Trainee Profile:
Name of Candidate
Gender Male Female other
Date of Birth Age
Contact phone number Home: Mobile:
Email
Photograph
Facebook username
Marital status Single Married Divorced Widowed
Religion of the candidate Buddhist Christian Jain Other
Current status (please specify) Student Working other
Yearly income of the candidate
(in Rs.)
Education Qualification Below 8th 8th 10th 12th Graduation Other
This section is to be filled by PIA after selection of the candidate
Passing year
University/Board of highest
qualification
Percentage/Grade
Technical Qualification ITI Other Other, please specify
Previously undergone skill If yes please specify
Yes No
training number of programs
If yes please specify
Work experience Yes No
number of years
Type of work Location work
Aadhar number Enrolment no(uid)
RSBY Card number53
Job card number/NREGA
BPL Ration Number
Driving Two
Antyodaya anna yojana ration wheeler
license
card no
number LMV
Own a bank account Yes No Name of bank
Do you have any insurance
Yes No If yes please specify PMSBY PMJJBY
coverage
Category SC ST Native language
Language known (basic,
Read Write Speak
medium, good, excellent)
Native
Hindi
English
others
T.B Epilepsy
PWD type, please specify if Chronic disease if
applicable any, please specify Other:
B. Family Details :
Marital Status of Head single Married
Name of head of the family
of the Family Widowed Divorced
Occupation of the Head of
Farmer Laborer Other, please specify
the Family
Number of family
Number of members in the
members working
family
outside village
Is any family member of
candidate an SHG Yes No Name of SHG
member?56
Monthly income of the Monthly expenses of
family (in Rs.) the family (in Rs.)
Total land owned by family Agricultural land (in
(in acres) acres)
Family details:
Enrolled
Highest Monthly in
Name of family Phone
Relation Age M/F level of Occupation income NREGS
member number
education (in Rs.) or Skill
training
56
Screen shot from [Link] with Name of SHG, SHG Id and name of member shall been closed along with declaration
from SHG office bearer stating candidate is part of the family of SHG member
C. Residence details :
House
Near landmark:
number:
Street: Block:
Present Village: Police station:
Address
Post office: District:
State Pin code:
House
Near landmark:
number:
Street: Block:
Permanent
Address
Village: Police station:
(if different
from above)
Post office: District:
State Pin code:
Own house Yes No Electricity availability Yes No
Number of living rooms in Number of Vehicles in
house house
Biogas Coal Electric Stove
Type of cooking material
Wood Kerosene LPG
used (check all applicable)
Smoke Less Chuha Cow dung Other:
D. Candidate interests and preferences:
1. 2.
Trades you are interested N.A. (I am open to any
in trade)
Preferred duration of Salary expectation after
training training
Have you met any Alumni If yes, please specify how
NO YES
from the Training program many :
Have you met any If yes, please specify how
NO YES
employers many
Is any of your family or
friends planning to join If yes, please specify how
NO YES
the training program with many
you
Are you willing to migrate Yes, willing to migrate Yes, willing to migrate
No
for training within the state anywhere for training
Are you willing to migrate Yes, willing to migrate Yes, willing to migrate
No
for work within the state anywhere for work
What motivates you to
Job Certification Other, please Specify:
join the training
Plan to continue studies
Yes No Certification
after Training
Training center
Gram Panchayat Friends
representative
How did you hear about
this training
Family Other, please specify
Declaration:
I, _ S/o, W/o, D/o. Hereby declare that the
information provided above is true to the best of my knowledge & belief .
If selected for training, I hereby undertake:
a. To attend and participate in all the sessions/classes of the aforesaid training program diligently
b. To maintain discipline and follow the instructions of the trainer, while undergoing the said training
program:
c. To Successfully complete the training program ; and
I understand that I will be deemed ineligible for assessment and certification un less, I
fulfill the
Signature of the candidate
The following documents are attached:
2 photos
Photo identity proof
Document as proof of identity (Aadhar card, Voter ID/Driving License or any other
ID/card issued by Govt. of India)
Document as proof of domicile (Ration Card or any other)
BPL card or Certification by Panchayat authority / Job Card (MNREGA)/RSB:Y Card/
Antyodaya Anna Yojana Ration Card/SHG certificate/PIP list approved by Gram Sabha
Proof of SC/ST/OBC/Minority/PWD, if applicable.(PWD-self declaration can be accepted)
Proof of Educational qualification (Copy of educational certificates, self-attested)
Signature of Applicant
Bank Account tracking
I, _ Son/Daughter/Wife of _ here by allow Ministry of Rural
Development to view my bank transactions, in order to track timely receipt of my salary and benefits that I
receive in my bank account, for a period of 18 months.
Bank account number :
Name of Bank :
Branch name :
District :
IFSC code :
Date Signature of the candidate
Declaration of Guardian57
I, S/o/W/o/D/o hereby declare that the
information provided by _ Name of Candidate S/o/W/o/D/o_ _
above is true and correct. I also declare that he / she does not have any police case pending.
I hereby give my approval to be held accountable for Name of candidate indiscipline /
dropping out from training / job after one year of joining of the DDU-GKY.
Relation to candidate :
Address :
Phone no :
Occupation :
Date of Birth (dd/mm/yyyy):
I understand that I can be contacted by any private / government agency involved in DDU-GKY
For any further query related to candidate for a period of 18 months.
Date: Signature of the guardian