REGISTRATION FORM Registration For Diabetes Sub-centerE-clinic-sub-center Name Of Doctor Assistant (H.W.) Father's Name Date of Birth Gender MaleFemaleOther Category GENOBCSCST Permanent Address- Village/Mohalla Post/House No. Distt. Pin Code State Andhra PradeshArunachal PradeshAssamBiharChandigarhChhattisgarhDelhiGoaGujaratHaryanaHimachal PradeshJammu and KashmirJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandWest Bengal ID Details Educational Qualification - High School Intermediate Paramedical/Allied Health Courses Basic Computer & Information Technology Rural Telemedicine Health & Wellness E-Clinic Sub-Center/Diabetes Sub-center Address- Village/Mohalla Post/House No. Distt. Pin State Andhra PradeshArunachal PradeshAssamBiharChandigarhChhattisgarhDelhiGoaGujaratHaryanaHimachal PradeshJammu and KashmirJharkhandKarnatakaKeralaMadhya PradeshMaharashtraManipurMeghalayaMizoramNagalandOdishaPunjabRajasthanSikkimTamil NaduTelanganaTripuraUttar PradeshUttarakhandWest Bengal Email Id Mobile No. Whatsapp No. Center Building OwnRental Internet or Electric Facility Available at Your Center YesNo If You have Experience with Registered Medical Practitioner(IMC Act,1956) YesNo How Many Year Experience Distance From the Government to Your E-Center (In kilometer). Upload Your Photograph Upload Your Aadhar Front/back Photograph Upload Highschool Marksheet/Certificate Self attested Upload Intermediate Marksheet/Certificate Self attested Upload Paramedical/Allied Course Marksheet/Certificate Self attested Upload Signature Doctor Assistant Inspection officer name with code/Self ☑ I declare that all the information and statement given by me as above are true and correct. If any information and statement are found to be wrong and false submitted by me at any stage, any disciplinary action can be taken by authority.
