Karyakarta Registration Form
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English
Constituency Details
District
*
Other
Agar Malwa
Alirajpur
Anuppur
Ashoknagar
Balaghat
Barwani
Betul
Bhind
Bhopal
Burhanpur
Chhatarpur
Chhindwara
Damoh
Datia
Dewas
Dhar
Dindori
Guna
Gwalior
Harda
Hoshangabad
Indore
Jabalpur
Jhabua
Katni
Khandwa (East Nimar)
Khargone (West Nimar)
Mandla
Mandsaur
Morena
Narsimhapur
Neemuch
Panna
Raisen
Rajgarh
Ratlam
Rewa
Sagar
Satna
Sehore
Seoni
Shahdol
Shajapur
Sheopur
Shivpuri
Sidhi
Singrauli
Tikamgarh
Ujjain
Umaria
Vidisha
Vidhan Sabha
*
Ward No.
*
Street
*
Booth No.
*
Personal Details
Member Name
*
Advocate
Doctor
Engineer
Honorable
Miss.
Mr.
Mrs.
Pandit
Thakur
सुश्री
Date of Birth
*
Blood Group
Select Blood Group
A-
A+
AB-
AB+
B-
B+
None
O-
O+
Marital Status
*
Select marital Status
Divorced
Married
Unmarried
Widowed
Date of Marriage
*
Gender
*
Male
Female
Other
Father's Name
Husband Name
Religion
*
Enter your Religion
Buddhism
Christianity
Hinduism
Islam
Jain
Sikhism
Category
*
Select Category
General
OBC
SC
ST
Voter ID No.
*
Invalid Voter ID format. It should be 3 uppercase letters followed by 7 digits (e.g., ABC1234567).
Caste
*
Literacy
*
Select Literacy
Educated
Uneducated
Qualification
Select Qualification
10th / 12th
Graduation
Diploma
Post-Graduate
PhD
Under Matric
No. of Children
No. of Daughters
No. of Sons
The number of daughters and sons combined must equal the total number of children and cannot exceed it.
S.No.
Select Type
Name
Date of Birth (DD/MM/YYYY)
Marital Status
Contact details
Mobile No.
*
Enter a valid 10-digit mobile number
WhatsApp No.
*
Enter a valid 10-digit mobile number
Email ID of Applicant
Invalid email address
Permanent Address Line 1
*
Permanent Address Line 2
Enter your locality
City / Village
*
District
*
Other
Agar Malwa
Alirajpur
Anuppur
Ashoknagar
Balaghat
Barwani
Betul
Bhind
Bhopal
Burhanpur
Chhatarpur
Chhindwara
Damoh
Datia
Dewas
Dhar
Dindori
Guna
Gwalior
Harda
Hoshangabad
Indore
Jabalpur
Jhabua
Katni
Khandwa (East Nimar)
Khargone (West Nimar)
Mandla
Mandsaur
Morena
Narsimhapur
Neemuch
Panna
Raisen
Rajgarh
Ratlam
Rewa
Sagar
Satna
Sehore
Seoni
Shahdol
Shajapur
Sheopur
Shivpuri
Sidhi
Singrauli
Tikamgarh
Ujjain
Umaria
Vidisha
Pincode
*
Membership Details
Others
Condition Of House
*
Select Condition
Pakka house upto 600 sq/ft.
Kaccha house
Pakka house above 600 sq/ft.
Have You Downloaded Namo App?
*
Yes
No
Ayushman Card
*
Yes
No
Other Health Card
*
Yes
No
Upload Photo
*
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