Request for New Head of Family

Please specify the reasons you wish to be identified as a new Head Of Family under MHIS
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Newly Married Newly Married
Others (Please specify)
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Please fill in the following details about yourself
Name as per EPIC (Mandatory)
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Required First Required Last
Father's/Mother's Name
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First Last
House number as per EPIC (Mandatory) *
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Gender (Mandatory) *
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Male
Female
Address as per EPIC (Mandatory) *
N/A
District (Mandatory) *
N/A
Name of block (Mandatory) *
N/A
Phone No *
N/A

+1

+1
Upload EPIC front side *
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Upload file
Upload EPIC back side *
N/A
Upload file
Upload your signature (Mandatory) *
N/A
Upload file
Please fill in the following details about your spouse
Spouse's name as per EPIC
N/A

First Last
Spouse's father's/mother's Name
N/A
Spouse's house number as per EPIC
N/A
Spouse's gender *
N/A

Male
Female
Spouse's address as per EPIC
N/A
Upload Spouse's EPIC
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Upload file
I would like to appear as a New Head of Family (HoF) in the MHIS Database in the coming years. I hereby declare the above information to be true to the best of my knowledge.
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I Agree
*
I Agree
Required

Please fill in the following details about yourself