Form Fill | Prime Laravel Form Builder

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Minutes

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Details of Applicant

Scheme Type

Applicant Name (As per Aadhar Card) *

Father/Husband Name *

Mobile Number *

Gender *

Date of Birth * *

Age *

Category *

Address

EasyCity Code Information

Address *

Bank Details

IFSC Code *

Bank Name *

Branch Name *

Account Number *

Other Details

Applicant Family Annual Income *

Is Disabled ? *

Yes

Are you in receive of Financial Assistance from any other agency.? *

Yes

Have you applied for Portugal or any other Passport.? *

Yes

Select Document Type *

File Upload

Applicant Photo (Image) *

Take Selfie

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Remark

I hereby declare that the above information is true to the best of my knowledge and belief. *