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 name Last name Gender MaleFemale Father's Name First name Last name Mother's Name First name Last name Address Police station Pin code Email Phone no 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? YesNo Any four wheeler (car, van or truck etc.) owned by any member of the household? YesNo Whether any member of the household is Assessee under GST? YesNo Whether any member of the household is Income Tax/Service Tax/Professional Tax Payee? YesNo Total annual household income from all sources (in RS) What is the main source of income of family? Do you own a House? YesNo Area? Do you own a residential plot? YesNo Own area? I/We declare that the information given above is 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 a hearing problem verified by a registered medical professional and I am/are not able to obtain proper aid due to my financial condition. Agree
