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Name of Trainee
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Date of Birth
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ANDAMAN & NICOBAR
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th
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th
10
th
12
th
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Choose State where you would like to pursue training
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ANDAMAN & NICOBAR
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA & NAGAR HAVE
DAMAN & DIU
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU & KASHMIR
JHARKHAND
KARNATAKA
KERALA
LADAKH
LAKSHADWEEP
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
ODISHA
PUDUCHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTARAKHAND
UTTAR PRADESH
WEST BENGAL
District
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Name of the selected Job Roles (Preference 1)
Training Institute
Duration
Name of the selected Job Roles (Preference 2)
Training Institute
Duration
Account Holder Name
Bank Name
Branch Name
Active Bank Account Number
IFSC Code
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