WeConnect Jan Seva Kendra
APPLICATION FORM for Individual
To
PHOTO
The Officer in charge,
Citizencenter Technologies Private Limited
First Name
_______________________________
Middle Name
_______________________________
Surname
_______________________________
Date of Birth (DD/MM/YYYY): ______________________
Sex: M / F
________________
Marital Status:
___________________________
Sir,
I wish to apply for a “Weconnect Jan Seva Kendra” in the below mentioned location. My particulars
are given below:
Address:
Village/Town:
PO:
Taluka:
Block:
District :
State:
PIN :
Father’s /
Husband’s
Name
Phone No. [R] _______________ [M] __________________
E mail id :
Period of Stay at current location (in Yrs)
Please furnish the following Important Information
Education: _______________________________________________________________________
Qualification : / Diploma / Professional Courses ____________________________________________
Computer Skills : Basic / Intermediate / Advance _________________________________ [Specify]
1 | P a g e WeConnect Jan Seva Kendra (PEC)
Address Proof: Voters ID / Driving License / Passport / Ration Card / Aadhar Card
No. _______________________
References:
1.
Name:____________________________________ Phone: _________________________
Address: ___________________________________________________________________
2.
Name: ____________________________________Phone: __________________________
Address: ____________________________________________________________________
Economical and Financial Indicators :
1.
Average Monthly Income [Rs.] ____________________________ Proof Available [Y/N]
2.
Profession : ___________________________________________________________
3.
Bankers Name: ___________________________ A/C No. ______________________
4.
Pan No : ________________________
5.
Fix Asset Details with Proof :
6.
Remarks ( Network Partner )
Proposed Citizen Center Details:
1.
Village / Location: _____________________________________________________
Taluka / Block: _______________________________________________________
District: ____________________________________________________________
Pin Code: ___________________________________________________________
State: ______________________________________________________________
Population Covered within 5Kms: _________________________________________
2.
Property Status : [Own / Rented ]
3.
Shop Area in Sq. Ft : ______________ Landmark ______________________________
4.
Property Address : _____________________________________________________
____________________________________________________________________
5.
Nearest Bank Branch : ___________________________________________________
6.
Availability of BSNL / Broadband : _________________________________________
2 | P a g e WeConnect Jan Seva Kendra (PEC)
Citizen Center Eligibility Criteria
1.
Preferably between the age group of 20-30:
2.
Qualification required 12th pass/ Graduate:
3.
Computer literate, possessing entrepreneurial skills:
4.
Should be able to arrange min. 250 sq.ft of space
5.
Should be the resident of area where the Citizen Center will be set up:
Documents Required for the Individual
ID Proof
Aadhar Card / Pan Card / Driving License / Passport
Center Location Proof
7-12 Extract / Sale Deed / Leave and License Agreement / Electricity Bill /
Property Tax Bill
Age Proof
Driving License / SSC certificate / School Leaving Certificate
Education Proof
Passing certificate of the 12th Class or above
Photograph
4 passport size color
Infrastructure Requirements
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Suitable Connectivity, Preferably Broadband
1 Latest Technology PC with licensed software
1 Table 4 ft.*2 ft.
Chairs - 5 no’s
Cupboard with Lock
Soft Board Blue Colored 2 ft.*5 ft.
Sign Board – 6 ft. * 4 ft. (Design will be provided)
1 Full UID kit with Laptop/IRIS/Biometric/Printer Etc.
1 PVC Printer
Signature of the Applicant –
Date – ____/_____/_________

All the Information given in this application is true and if any found wrong, I myself will be responsible for
the same.
3 | P a g e WeConnect Jan Seva Kendra (PEC)
1.
For Internal Use of CCTPL Officials Only:
Importance of the proposed location:
2.
Special Remark if any:
Name of the Representative: ________________________________________________
Signature of the Representative:______________________________________________
Date: ____/_____/_________
4 | P a g e WeConnect Jan Seva Kendra (PEC)