Beneficiary Registration Form under PMMVY

(1st Child or 2nd Girl Child)

Name of SSK______________________________ASHA Name_________________________

1 Is beneficiary an employee of Central Govt., State Govt. YES / NO

or PSU?
2 Number of living children 0/1/2/3/4
3 Does the Beneficiary have Aadhaar Card? YES / NO
4 Name (As per Aadhaar)

5 Aadhaar Number (Attached the document)

6 Date of Birth
7 Age (in Years)
8 Category SC / ST / Others
9 Mobile Number (10 digits)
10 Eligibility Criteria ( Sl. No. Choose from below)
11 Identity No. (Attached the document)
12 MCTS/RCH ID
13 MCP Card Registration Date
14 Last Menstrual Period (LMP) Date
15 Ante-Natal Check-up (ANC) Date*
16 Has the child been born YES / NO
17 Actual Date of Childbirth
18 Address

19 State/District/Block WB/UD/
20 Village (Census)
21 PIN Code
22 Number of Child Birth (Present Pregnancy) 1/2
23 Type of Institute of Child Birth
24 Name of Institute of Child Birth
25 Date of Vaccination (Birth Dose)
26 Date of Vaccination (6 Weeks)
27 Date of Vaccination (10 Weeks)
28 Date of Vaccination (14 Weeks)

1. Women whose net family income is less than Rs. 8 Lakh per annum
2. Women holding MGNREGA Job Card
3. Women farmers who are beneficiaries under Kishan Samman Nidhi
4. Women holding E-shram card
5. Women Beneficiaries under Pradhan Mantri Jan Aarogya Yojana (PMJAY) under Ayushman Bharat
6. Pregnant and Lacta ng AWWs/ AWHs/ ASHAs
7. Women holder of BPL ra on Card
8. Women who are par ally (40%) or fully disabled (Divyang Jan)
9. SC Women
10. ST Women
11. Women Beneficiaries holding the ra on card under Na onal Food Security Act 2013

HOOGHLY