NEW

UAN to be provided Previous Member Id BETWEEN INITIAL AND NAME

only if available PLEASE GIVE SPACE ONLY

Mandatory
1 2 3
UAN MEMBER ID MEMBER NAME
MUTHUGURUSAMY MURUGAN
 NEW MEMBER REGISTRATION

ANY ONE OF THE

FOLLOWING

M-MALE
Valid date in dd/mm/yyyy Valid date in dd/mm/yyyy F-FEMALE
format format T-TRANS GENDER

Mandatory Mandatory Mandatory

4 5 6
DOB DOJ GENDER
07/06/2001 02/05/2019 M
 ANY ONE OF
THE
FOLLOWING

F-FATHER
BETWEEN INITIAL AND NAME H-HUSBAND
PLEASE GIVE SPACE ONLY

Mandatory Mandatory
7 8 9 10
Father’s/Husband Name Relation Mobile Number Email ID
MURUGAN F 9655240045
 ANY ONE OF THE FOLLOWING
ILLITERATE-I
LITERATE-L
NON-MATRIC-N
MATRIC-M
SENIOR-SECONDARY-S
GRADUATE-G
POST-GRADUATE-P
PF Wages as on Joining in DOCTORATE-D
TECHNICAL (PROFESSIONAL)-T
Mandatory
11 12 13
Nationality WAGES QUALIFICATION
Indian S
 ANY ONE OF THE
ANY ONE OF THE FOLLOWING FOLLOWING
M-MARRIED
U-UN MARRIED
W-WIDOW/WIDOWER
D-DIVORCEE N-NO
Y-YES

Mandatory Mandatory Mandatory

14 15 16
Marital Status International Worker Country of Origin
U N
 17 18 19
Passport Number Passport Valid From Date Passport Valid Till Date
 ANY ONE OF THE
ANY ONE OF THE FOLLOWING FOLLOWING

L-LOCOMOTIVE
N-NO V-VISUAL
Y-YES H-HEARING
L H V

Mandatory
20 21 22 23
Is Physical Handicap Locomotive Hearing Visual
 24 25 26
Bank Account Number Bank IFSC Name as per Bank
 27 28 29
PAN Name as on PAN AADHAAR Number
973016547172
 30
Name as on AADHAAR
MUTHUGURUSAMY MURUGAN