Application for Admission in Phlebotomy Course for CSC-VLEs

VLE Details

USHA JAISWAL
VLE Name

242162540019
CSC ID

CHURTELA
GP/Ward

DABHARA
Block Passport size photograph of
Applicant
JANJGIR-CHAMPA
District

CHHATISGARH
State

ushajaiswal130@gmail.com
Email

9340542048
Mobile

Applicant Details (Science Stream is Mandatory in 12th Standard)

JAISWAL
First Name: DEENA Last Name:

12/10/2001
Gender: Male/Female [ F ] Date of Birth:

20
Marital Status Married/Single[ S ] Age (Years):
Mobile
8234076467
Number: Landline Number:
Aadhaar Card /
289798461946
E-mail ID: EID No.:

Address Details

Permanent Address
Current Address

WARD NO-5 WARD NO-5

Door Number: Door Number:

KANSA MOD KANSA MOD

Street Name: Street Name:

CHURTELA CHURTELA
Village/City: Village /City:
 JANJGIR-CHAMPA JANJGIR-CHAMPA
District: District:

CHHATISGARH CHHATISGARH
State: State:

495688 495688
Pin code: Pin code:

Family Details

Family Details Guardian's Details

Fathers'
RAGHUNARAYAN RAGHUNARAYAN
Name: Guardian's Name:
Mother's
BHAGWATI FATHER
Name: Relationship:
Father's
FARMER FARMER
Occupation: Occupation:
Mother's Guardian's Contact
HOUSE WIFE 9111749003
Occupation: No. :
Father's
9111749003
Contact No. :
Family
OBC
Income: Category:

HINDU KALAR
Religion: Caste:

Education Details Work Experience

Education Experience in
12TH
Qualification: Years:

2017
Pass out year: Current Employer:

Institution: Employer Address:

% Marks
358/500
obtained:

Along with this they need to give:-

1)Aadhar card copy or any other residential proof.
2) ID proof other than residential proof
3) Qualifications document marksheet and passing certificate of 10+2