Enrollment

Please fill up the enrollment form along with present medical condition to be eligible for free hearing device as per your need.

Name *

First

Last

Gender

Male
Female

Mother’s Name *

First

Last

Father’s Name

First

Last

Address *

Police Station *

Pin code *

Email *

Mobile Number *

Do you have Ration Card?

Yes

Ration Card Category *

If you belong to BPL/AAY Category then provide BPL Registration No.

Any two wheeler or three wheeler owned by any member of the household? *

Yes
No

Any four wheeler (car, van or truck etc) owned by any member of the household? *

Yes
No

Whether any member of the household is Assessee under GST? *

Yes
No

Whether any member of the household is Income Tax/Service Tax/Professional Tax Payee? *

Yes
No

Total annual household income from all sources (in Rs) *

What is the main source of income of family? *

Do you own a House? *

Yes
No

Area?

Do you own a residential plot?

Yes
No

Area?

I/We declare that the informations given above are true to the best of my/our knowledge and belief thereof is false or no material information has been concealed. *

Agree

I/We declare that I’ve hearing problem verified by registered medical professional and I am/are not able to obtain proper aid due to my financial condition. *

Agree

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