Passing Year

University /Board of highest

Qualification Percentage/grade

Other, Please Specify

Technical Qualification ITI Otrher
If Yes Please specify the
Previously undergone skill training Yes No Name of program

If Yes Please specify the

Work Experience Yes No number of years

Type of Work Location of Work

Enrollment EID
Aadhaar Card
RSBY Card Number
Job Card/NREGA
BPL Ration Card No

Driving Two Wheeler

Antyodaya Anna Yojna Ration Card
Licence
Number
Number LMV

Own A Bank Account Yes No Name of Bank

PMSBY PMJJBY
Do You Have A Insourance Coverage Yes No If Yes, Please Specify
Other
Category SC ST Native Langauge

Native Read Write Speak

Hindi Read Write Speak

Language Known Basic
Medium Good Exellent
English Read Write Speak

Other: Read Write Speak

PWD Type, Please Chronic Disease If Any , T.B Epilespy

Specify If Applicable Please Specify Others:

Or alternative records used by RSBY , as notified by the state Government

Pradhan Mantri Suraksha Bima Yojna
PMJJBY: Pradhan Mantri Jeevan Jyoti Bima Yojna
B Family Profile :

Marital Status of Head Single Married

Name of the Head of Family
of Family Widowed Divorced
Farmer Labourer
Occupation of The Head of Family Other , Please Specify

Number of Family
Numbers of family Members in the
Members working
family
outside village

Is any family member of canidate an

Yes No Name of SHG
SHG member

Monthly Income of The Family Monthly expenses of the

(in Rs.) family (In Rs.)

Agriculture Land( in
Total Land Owned by family in acers
Acers)

Family details :
ENROLLED
Highest
Name of Family Phone Monthly IN NREGS
Relation Age M/F Level of Occupation
Member Number Income in Rs OR SKILL
Education
TRAINING

Father M

Mother F

Screenshot from nrlm.gov.in with Name of SHG, SHG id and Name of member shall be enclosed
along with decalration from SHG Officer bearer stating that candidate is part of the family of SHG member
C. Residence Details
House Number
Near
Street: Landmark
Village Block
Present Address Police
Post Office Station
Gram Panchayat District
State Pin Code :
House Number
Near
Street: Landmark
Permanent Address
Village Block
if different from
Police
above
Post Office Station
Gram Panchayat District
State Pin Code :
Electricity
Own House Yes No Yes No
Available
Number of
Number of Living
vehicles in
Room in house
House

Type of cooking Biogas Coal Electric Stove

material used(check wood Kerosene LPG
all applicable Smokeless Chullha Cow dung Other :
D. Candidate Ineterest and Prefences
Trades you are 1 2
N.A (I am Open to any Trade)
interested in
Preffered Duration of
Salary Expectation After Training:
Training
Have you met any
alumni from the training No Yes If yes please specify how many
program
Have you met any
No Yes If yes please specify how many
employers
Is your family or friends
planning to join the
No Yes If yes please specify how many
training program with
you
Are You Willing to Yes Willing To Migrate Anywher
No Yes Willing To Migrate Within The State
migrate for training For Training
Are You Willing to Yes Willing To Migrate Anywher
No Yes Willing To Migrate Within The State
migrate for work For Work

What Motivates you to

Job Certification Others Please Specify:
join the training

Plan to Continue Studies

Yes No Uncertain
after training

Gram Panchayat Friends Training Center Representative

How did you hear about
this training
Family Other Please Specify
Declaration:

I , __________________________________________ S/o W/o D/o __________________________________________ hereby declare

that the information provided above is true to the best of my knowledge and belief.

If Selected for tarining , I hereby undertake:

a. To attend and participate in all the sessions/classes of the aforesaid training program diligently
b. To Maintain discipline and follow the instruction of the trainer , while undergoing the said training program;

c. To Successfully complete the training program; and

I understand that I will be deemed ineligible for assessment and certificarion unless, I fullfill the above criteria and meet the
assessment standards.
Signature of the Candidate
The Following Documents are attached:
> 6 photos
> Photo Identity Proof
> Document as proof of identity (Aadhar cardNoter ID/Driving Licence or any other ID/card issued by Govt. of India)
> Document as proof of domicile (Ration Card or any other)
> BPL Card or Certification by Panchayat Authority/ Job card (MNREGA)/ RSBY Card/
> Antyodaya Anna Yojana Ration Card/ SHG certificate/PIP list approved by GramSabha
> Proof of SC/ST/OBC/ Minority/PWD, if applicable. (PWD-self declaration can be accepted)
> Proof of Educational Qualification (Copy of educational certificates, self-attested)

Signature of Applicant

Bank Account Tracking

I, _________________________________ Son/ Daughter/ Wife of ______________________________hereby allow Ministry of Rural

Development to view my bank transactions, in order to track timely reciept of my salary and benefits that I receive in my bank
account, for a period of 18 months.

Bank Account Number:

Name of Bank:

Branch Name:

District:

IFSC Code

Date : Signature of the candidate

 Declaration of Gaurdian

I , __________________________________________ S/o W/o D/o __________________________________________ hereby declare

that the information provided by __________________________________ (Name of Candidate) S/o W/o /D/o
______________________________________________ above is true and correct. I also declare that he she does not have any police
cause pending.

I hereby give my approval to be held accountable for ____________________________________________________ (Name of

Candidate ) indiscipline/dopping out from the training/job after one year of joining of the DDU-GKY.

Relation to candidate:

Address:
Phone No:
Occupation:
Date of Birth (dd/mm/yyyy):

I understand that I can be contracted by any private/government agency involved in DDU-GKY For any Further query related to
candidate for a period of 18 months.

Date Signature of the Guardian

Signature of Applicant

Guardian Can be Candidate's parent, relative, gram sabha member, Gram Panchayat Official or any elder who knows the candidat.
To be filled by PIA Officials:

House hold
Candidate NPR Tin Tin no (
Number (From SECC) From SECC)
Name of
Apptitute Test The Test
Conducted Yes No Conducted

Apptitude Test Score

Allocated Trade

Comment if any

Remarks by trainers/mobilizer who have interacted with the candidate

Soft Skill Trainer:

Domain Trainer:

Mobilizer :

Selected for Training : Yes/No

If No , resaon for elimination:

Signature of the PIA Represntative

Designation, Name

Designation, Name

Designation, Name

58 Candidate Can be identify in Socio Economic Caste Census (SECC) database using the following variables :
State Districts , Tehsil, Towns Villages / Block Number (If available , Name of the candidate , Name of Father , Name of Mother
59 If Candidate cannot be identified , Candidate 's Household can be identified by first identifying Candidate's Parent using granparents
name and then noting down Household Tin Number
60 PIA is Suggested to form a 4 member Core committee consisting of one domain trainer , one soft skills trainer, One IT Trainer

headed by mobilizer. The candidate must be screen based on reponses in the screen form and on the perception of core committee member.
 Ministry of Rural
DevelopmentGovernment of India

Techno India

SF5.1G2: Parent’s Consent Form (अभििावक सहमभि प्रपत्र)

Name of the candidate ________________________________
अभ्यार्थी/ अभ्याभर्थि नी का नाम
Candidate's father's name ________________________________
अभ्यार्थी/ अभ्याभर्थि नी के भपिा का नाम
Candidate's mother's name _______________________________
अभ्यार्थी/अभ्याभर्थि नी के मािा का नाम
Basic information
आधारभूत सूचना -------

1) The DDU-GKY Skills programme is run by the Ministry of Rural Development, Government of India with
to train and place rural poor youth in the age group of 18-35 years.
कौशल कार्िक्रम िारि सरकार के ग्रामीण भवकास मं त्रालर् द्वारा 18 से 35 आर्ु समू ह के ग्रामीण गरीबी रे खा के नीचे (बी0पी0एल0) र्ुवाओं
को प्रभशभिि करना व रोजगार भिलाने हे िु सं चाभलि है ।
2) Under the DDU-GKY Skills programme,(Techno India), Jind Haryana will provide skills training in Multi
Skill Technician (SSC/Q3115) + Sewing Machine Operator (AMH/Q0301) Version 2.0 + Pressman
(AMH/Q0401) Version 2.0 for __________________(duration of courses in hours).
आजीभवका कौशल कार्िक्रम , टे क्नो इं भिर्ा ,जींि हररर्ाणा द्वारा______________________ पाठ्यक्रम में
____________घण्टे की अवभि के भलए कौशल भवकास प्रभशिण प्रिान करे गा ।
3) On completion of the training, the PIA will assist to place him/her in a job as per his/her proficiency for a
monthly minimum salary of Rs. 6,000 per month.
प्रभशिण पूणि होने पर पी0आई0ए0 अभ्यार्थी/अभ्याभर्थि नी को उसके /उसकी कुशलिा के आिार पर कम से कम ₹ 6000/- माह
के पाररश्रभमक पर रोजगार भिलाने में सहार्िा करे गा ।
4) During training, your ward will be trained on the course specific skills; soft skills, life skills, and computer
handling skills.
प्रभशिण के िौरान आपके बच्चे को पाठ्यक्रम भवभशष्ट कौशल जै से - मृ िु कौशल (सॉफ्ट स्किल्स), जीवन कौशल (लाइफ स्किल्स)
एवं कंप्यू टर सं चालन कौशल में प्रभशभिि भकर्ा जार्े गा।
Entitlements अनुमन्य सु भविार्ें :-
Your ward is entitled to the following: आपका वािि भनम्नभलस्कखि का हकिार है :
1) Training without any payment.
भन:शु ल्क प्रभशिण ।
2) Free accommodation and food. If candidates opts for non-residential training Rs 125 for 8 hours of
 Ministry of Rural
DevelopmentGovernment of India

training completed will be credited to the bank account of the candidate once in 15 days for regular
training and once in a month for part time training.
भन:शु ल्क िोजन व आवास की व्यवस्र्था । र्भि अभ्यार्थी/ अभ्याभर्थि नी अनावासीर् प्रभशिण का चर्नकिाि है िो 8 घण्टे के प्रभशिण हे िु उसे

रूo

125/- भिर्ा जार्ेगा। भनर्भमि प्रभशिण प्राप्त करने पर एक माह में एक बार अभ्यार्थी/ अभ्याभर्थिनी के बैंक खािे में उसकी उपास्कस्र्थभि के
अनु सार
रू 125/- प्रभिभिन की िर से िु गिान भकर्ा जार्ेगा ।
3) Candidates who complete their training and get placed will receive post placement support of
जो अभ्यार्थी/ अभ्याभर्थि नी प्रभशिण पूणि करके रोजगार प्राप्त करें गे उनको रोजगार प्रास्कप्त के उपरां ि सहार्िा भनम्नवि प्रिान की जार्ेगी

 Rs. 1270 per month for 2 months for the Placements within District of domicile
 अपने मू ल जनपि में नौकरी करने पर रू0 1270 प्रभि माह की िर से िो माह के भलए है ण्डहोस्कडंग सपोटि ।
 Rs. 1270 per month for 3 months for the Placements within State of domicile
 अपने मू ल प्रिे श में नौकरी करने पर रू0 1270 प्रभि माह की िर से िीन माह के भलए है ण्डहोस्कडंग सपोटि ।
 Rs. 1270 per month for 6 months for the Placements outside State of domicile
 अपने मू ल प्रिे श के बाहर नौकरी करने पर रू0 1270 प्रभि माह की िर से छ: माह के भलए है ण्डहोस्कडंग सपोटि ।
4) All candidates will be provided an uniform on the day the training starts:
सिी अभ्यार्थी/ अभ्याभर्थि नी को प्रभशिण शु रू होने के भिन पोशाक (र्ूभनफॉमि ) प्रिान भकर्ा जार्ेगा :

 One pair in case of 3 month or 6 month course

 अ) िीन र्ा छः माह के प्रभशिण हे िु एक जोडी पोशाक
 Two pair in case of 9 month or 12 months
 ब) 9 र्ा 12 माह के प्रभशिण हे िु िो जोडी पोशाक।
5) A bank account will be opened by the PIA for all candidates in the first month of training
प्रभशिण के प्रर्थम माह में पी0 आई0 ए0 द्वारा प्रत्ये क अभ्यर्थी का बैंक में खािा खोलना सु भनभिि भकर्ा जाएगा।
6) All candidates will be assessed free of cost and those who pass will be given Training Certificate as per
___________ (NCVT/SSC) guidelines and assessed by ________________ (assessing agency) .
प्रत्ये क अभ्यर्थी/ अभ्यभर्थि नी का एन0सी0वी0 टी0 /एस0 एस0 सी0 मागििभशि का के अनु सार मू ल्ां कन करने वाली संस्र्था द्वारा भन: शुल्क
मू ल्ां कन भकर्ा जार्ेगा िर्था उत्तीणि अभ्यर्थी को प्रमाण पत्र भिर्ा जार्ेगा।
7) At the time of placement, candidate will be given a Preliminary Offer Letter from the PIA which lists down
the expected remuneration and terms and conditions of employment. The candidate will receive this before
leaving his/her native place for the job.
 Ministry of Rural
DevelopmentGovernment of India

रोजगार हे िु अभ्यर्थी को पी0आई0ए0 द्वारा प्रार्थभमक बु लावा पत्र भिर्ा जार्ेगा ,भजसमें सं िाभवि पाररश्रभमक िर्था रोजगार की
शिें एवं िशाएं वणीि होगी , नौकरी के भलए अपने मू ल स्र्थान को छोडने के पू वि अभ्यार्थी को इसे प्राप्त करार्ा जाएगा ।
8)All candidates will receive training material free of cost including work books, note books and other study
materials.
सिी अभ्यर्थी /अभ्याभर्थि र्ों को वकि बु क ,नोट बु क एवं अन्य सामग्री सभहि समस्त प्रभशिण सामग्री भन:शु ल्क प्रिान की जाएगी।
9) If a candidate has not received the above entitlements, he/she can call or SMS the Helpline at
.................................. to register their complaints.
र्भि भकसी अभ्यर्थी को उपर्ुि क्त सु भविाएं नहीं प्राप्त होिी है िो वह इस हे ल्पलाइन नम्बर ....................................... पर
फोन करके, एस0एम0एस करके अपनी भशकार्ि िजि करा सकिा है ।

________________________
Your consent आपकी सहमभि
If you agree to admit your child in the training programme offered by Techno India
please sign below.
र्भि आप टे क्नो इं भिर्ा, जींि (हररर्ाणा) द्वारा प्रस्ताभवि प्रभशिण कार्ि क्रम में अपने बच्चे को प्रवे श िे ने के भलए सहमि हैं िो
कृपर्ा नीचे हस्तािर करें ।

__________________________
Parent signature अभििावक के हस्तािर
Date(भिनां क ): ______________________

Except this consent letter, PIA shall not take any affidavit / certificate from either the parent or the candidate.
इस सहमभि पत्र को छोडकर, पी0आई0ए0 अभ्यार्थी र्ा अभििावक से कोई शपर्थ पत्र / प्रमाण पत्र नहीं ले गा।