UNIK ONETOUCH SYSTEM PRIVATE LIMITED

Reg. Office: G-3 MAAN NAGAR JhunJhunu - 333001 IN
CIN No: U74999RJ2020PTC072338, e-mail: uitjjn@gmail.com, Ph. No.- +91 94621 03470,9829224956
-:LSP Detail:-

DC Name

Mobile No

Address

Email ID

Application form for eMitra Kiosk
Kiosk Owner Details

Kiosk Owner Name

Father's Name

Date of Birth (DD/MM/YYYY)

Permanent Address

Current Address

Kiosk Owner Adhar No.

Kiosk Owner E-mail ID

Paste your latest photo verified by LSP DC with seal

Kiosk Owner PAN No.

Jan Aadhar No.

Kiosk Owner Contact Number

1

2

Kiosk Center Details

Kioak Center Location

Kiosk Center Name

Kiosk SSO ID

Police Station (Thana)

Kiosk Address

Tahsil

Muncipal Town/Grampanchyat

Ward No./Village Name

Pincode

Kiosk Center Details

Kiosk Bank A/C Number

IFSC Code

Kiosk Bank & Branch Name

Account Holder Name

Kiosk Holder already have Kiosk Banking : Business Correspondent Details

Kiosk Bank Account Number

IFSC Code

Bank O/D Account No.

KO Code

Kiosk Owner Sign

LSP DC Sign with Seal

CIN No: U74999RJ2020PTC072338, e-mail: uitjjn@gmail.com, Ph. No.- +91 94621 03470,9829224956

UNIK ONETOUCH SYSTEM PRIVATE LIMITED

Reg. Office: G-3 MAAN NAGAR JhunJhunu - 333001 IN
CIN No: U74999RJ2020PTC072338, e-mail: uitjjn@gmail.com, Ph. No.- +91 94621 03470,9829224956
शर्ते एवं नियम

1. राज्य स्तर से निर्धारित दरों से अधिक राशि नहीं वसूलना।

2. ई-मित्र धारक को अपने रजिस्टर्ड पते पर ही ई-मित्र कियोस्क का कार्य करना है।

3. ई-मित्र कियोस्क पर विभाग द्वारा निर्धारित रेटलिस्ट एवं को-प्राण्डेड पैनर होना अनिवार्य है।

4. ई-मित्र धारक उपभोक्ताओं से विभागीय पेटलिस्ट अनुसार शुल्क लेंगे एवं उपभोक्ता को प्रत्येक ई-मित्र सेवा के लिए प्रिन्टेड रसीद देनी अनिवार्य है। किसी भी सर्विस में मोबाइल नम्बर ईमेल आईडी आश्यक हो तो कंप ग्राहक के ही मोबाईल नम्बर/ ईमेल आई डी का प्रयोग करना अनिवार्य है।

5. बिजली पानी / टेलिफोन बिलो के भुगतान मे सील का उपयोग करना वर्जित है।

6. ई-मित्र धारक को जिला ईमित्र समिति एवं विभाग के द्वारा समय समय पर दिए समस्त नियमो एवं निर्देशो की पालना करनी होगी।

7. निर्धारित प्रारूप में निरीक्षण, शिकायत एवं सुझाव रजिस्टर को संगारित करना होगा।

8. कियोस्क सत्यापित होने के पश्चात 15 दिवस में 15 के साथ अनुबंध पत्र हस्ताक्षर करना

मेरे द्वारा दी गई सभी जानकारी सत्य है तथा उपरोक्त शर्तें मेने ध्यानपूर्वक पढ़ समझ लिया है जिनकी मे पालना करूंगा/करूंगी ।

Date:

Place :

Kiosk Owner Signature

Filled by LSP

1.Kiosk Have Infrastructure (PC Internet)

2. VC Sctup

3. Training Given to Kiosk Holder

4. Rate List Banner

5. Co-Branded Banner

6. LSP Ensure that Applicant/Family Member of applicant/Kiosk Location not found in irrruglarties of emitra in Past.

Check List of Enclosure: (All photo copies must be self attaested by Kiosk Owner)

1. Police Verficvation Report

2. 10™ Marksheet Copy

3. Kiosk Bank Passbook Photocopy

4. Aadhar Photocopy

5. PAN Card Photocopy

6. Jan Aadhar Photocopy

7. Rent Agreement (In Case of Different GP/Block/District/State and in Urban Area)

8. Police Verification of Other District/State

9. Other Documents :-

All given details are correct in my knowledge, and completely fillied in application on E-Mitra Portal.

Date:

Place :

LSP DC Sign with Seal

CIN No: U74999RJ2020PTC072338, e-mail: uitjjn@gmail.com, Ph. No.- +91 94621 03470,9829224956

ANNEXURE-5

I / Weson / wife / daughter of , Jan Aadhar ID having my residence/office at solemnly affirm and state as under:

Whereas, I am the absolute Owner / Power of Attorney holder / Authorized Person in physical and lawful possession of the SSO ID to be mapped as kiosk owner SSO ID of proposed kiosk at Village/Street : GP/Ward: PS/MC:District Whereas, I have applied for allotment of kiosk through Local Service Provider (LSP for short) District and DO HEREBY SOLEMNLY AFFIRM, SAY AND UNDERTAKE THAT

1.  That I have read and understand unequivocal, the terms of conditions of Expression of Interest (EOI) no. F4.9 (795)/RISL/Tech/Misc./2020/20244008 dated 31-08-2020 and Agreement executed with executed between RajCOMP Info Services Ltd. (RISL) and LSP dated

2.  That I accept and agrees to abide by all conditions mentioned in EOI and Agreement and in case of default of my compliance with any of the conditions of the said EOI and Agreement, I shall be liable to be penalize according to the terms of EOI / Agreement and prevailing law in India.

3.  That I am giving this affidavit/undertaking in my acceptance to the terms of the EOI/agreement and I have received the copy of EOI and the Agreement.

4.  This undertaking shall be binding on me, our heirs, successors, legal representatives, assigns, agents etc. and who so ever derives the title through us.

Deponent

Verification

SOLEMNLY AFFIRMED at on this day of 20 . Place -

Deponent