Registration Form
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Applicant Details
Fields marked with * is mandatory
Registration For
*
Select
District-Level
State-Level
Do you have MPBA issued previously?
*
Select
Yes
No
Applicant First Name
*
Applicant Last Name
*
Father First Name
*
Father Last Name
*
Mother First Name
*
Mother Last Name
*
Date of Birth
(DD/MM/YYYY)
*
Your age as on 1st January of the calendar year of the date of this certificate.
Gender
*
Select
Male
Female
Choose birth proof document, you are uploading
*
Select
Birth Certificate
Medical Report
School Marksheet/10th Board Marksheet
Any other Authorized/Valid Document
Importance Notice: If you are uploading Birth Certificate than mandatorily fill below two details.
Date of Registration (As given in Birth Certificate)
Date of Issuance (As given in Birth Certificate)
Two identification marks
A)
B)
Nationality
*
Select
Indian
NRI (Non-Residential Indian)
Choose your nearest District Association for Application Verification
*
Select
ALIRAJPUR
ASHOKNAGAR
BADWANI
BALAGHAT
BETUL
BHOPAL
CHHATARPUR
CHHINDWARA
DATIA
DEWAS
DHAR
GUNA
GWALIOR
NARMADAPURAM
INDORE
JABALPUR
KATNI
KHANDWA
KHARGONE
MANDLA
MANDSAUR
NARSINGHPUR
NEEMUCH
PANNA
RAISEN
RAJGARH
RATLAM
REWA
SAGAR
SATNA
SEHORE
SEONI
SHAJAPUR
SHIVPURI
SINGRAULI
UJJAIN
VIDISHA
Present Address
*
Is Present & Permanent Address is same?
*
Yes
No
Permanent Address
*
Parents/Guardian
Mobile Number
*
Parents/Guardian
E-mail ID
*
Qualification Details
Current Qualification Pursuing Details
*
Select
School
College
Organisation
Name
*
Postal address
*
Mobile Number
*
E-mail address
*
In case of students, class in which studying as at 1st January of the calendar year of the date of this certificate
Class Details
School Name
*
School Address
*
Phone No
*
Class
*
Passing Year
--Select--
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Uploads
Applicant Passport Size Photo
*
Instruction:
1. Upload Photograph duly Attested by the School Head Master / College Principal /Head of organization or Gazetted Officer
2. Size 30Kb min 200Kb max.
3. Format jpeg/jpg only
Photo
Signature
Thumb Impression
Upload attested copy of birth certificate from the Birth Registering Authority
*
Size 30Kb min 200Kb max.
Importance Notice: Refer to attachment Annexure-II - ‘Age Estimation Format’ given under document section and undertake medical test from Govt. Hospital as per SAI format.
Upload filled and signed ‘Age Estimation Format’
*
Size 30Kb min 200Kb max.
Upload School Marksheet/10th Marksheet
*
Size 30Kb min 200Kb max.
Any other Authorized/Valid Document
*
Size 30Kb min 200Kb max.
Upload Affidavit filled by Parents or Guardians
*
Size 30Kb min 200Kb max.
*
Declaration
I hereby certify that the particulars given above are true and correct to the best of my knowledge and in accordance with the documents produced by me later for verification.
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