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New Center Registration

All fields marked with * are mandatory
Personal Details
Firm Name* : Center Owners Name :
Center Co-ord’s Name* : Center Co-ord’s Qualification :
State* : Region :
District : Block :
Place/ Location* : Date of Agreement :
Center Types* :
 
Center Address Details
Center Address* : Phone (with STD) :
Mobile :
Fax (with STD) :
Pin : Email* :
Password* : Confirm Password* :
 
Residence Address of Owner
Address : Pin :
Phone (with STD) :
Mobile :
Nature of field area :
 
Center Premises Details(Area in Sq Ft)
Classroom 1 : Classroom 2 :
Lab 1 : Lab 2 :
Office : Reception :
Others :
 
Hardware Details ( machines in No’s)
PIII : PIV :
PV : Others :
Digital Camera : Printers :
DMP 132 : DMP 80 :
Laser : Inkjet :
Others :
Internet connectivity :
Number of dedicated machines for online insurance training :
 
Software Details
Software Name :        
  
 
 
Faculty Details
Name : Qualification :
Experience :
 
 
Insurance Details
Sr.List of ContentsMakeModelSr.Value
0. Office Furniture
0. Student Furniture
0. Fixtures
0. Air Conditioner
0. Coolers
  
Affiliation Fees : Mode of Payment :
Date of Payment :
No of Books in Library(Value) :
Total Stationary in Use (Value) : Value of Centers Sign Boards :
 
Details of PA
Name of Center Owner : Father’s Name/Guardian :
Age of Center Owner : Name of Nominee :
Relation with Nominee :
 
Forwarding Section
Category* :