ASHA Component II Registration

You are registering for ASHA CERTIFICATION - ASHA Component II

Name

Display Name: First Name: , Middle Name: , Last Name:

Father's Name

Display Name: First Name: , Middle Name: , Last Name:

Mother's Name

Display Name: First Name: , Middle Name: , Last Name:

Date of Birth

Gender

Aadhar Number

ABHA(Ayushman Bharat Health Account) ID

Mobile Number

Note:
1. This mobile number will be used for OTP authentication.
2. * represents mandatory fields.

Permanent Address

House/Door/Flat No

Street/Locality/Area Name

Village/Ward No/Landmark

Country

State/UT

District

Pincode

Correspondence Address

Same as Permanent Address

House/Door/Flat No

Street/Locality/Area Name

Village/Ward No/Landmark

Country

State/UT

District

Pincode

Medium

Social Category/Caste

Disability

Nationality

Other Nationality

Disadvantage Group

Educational Qualification

I, the deponent, do hereby solemnly declare and verify that the contents of the above declaration are true to the best of my knowledge and belief, and nothing material has been concealed or suppressed therefrom. This electronic self declaration has been given with reference to IT Act 2000 and is admissible under The Indian Evidence Act 1872.

ASHA Component II Registration

You are registering for ASHA CERTIFICATION - ASHA Component II

Basic Detail

Address

Other Details

Declaration