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Name of Family Head *

Father's Name *

Address*

Permanent Address*

District*

Village*

Taluka*

Pincode*

Email*

Mobile*

Family Head Photo

Profile Image

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Family Members

Family Member Name	Gender	Disable	Date of Birth	Relation	Action

Card Option *

Document Image*

ResidenceDocument Option *

Is there a gas connection?

*The details given above are true to the best of my knowledge. I understand that if the particulars furnished by me are found to be false or untrue, the Electronic Family Card issued to me may be canceled and action may be taken against me under the Essential Commodities Act (Central Government Act 10) 1955 and other applicable laws.

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