Application Form for Setting-up Common Service Centre (CSC) Under District e-governance Society, Malkangiri

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2 Application Form for Setting-up Common Service Centre (CSC) Under District e-governance Society, Malkangiri NEW REGISTRATION (Tick on Registration Check Box for the Existing VLE which are already registered under CSC 1.0 Programme of this District) Name: Date of Birth : Gender : Marital status : Male / Female Un-married/ Married Father / Husband s Name : Applicant / CSC Name: Location : Rural / Urban Located in Gram Panchayat office(y/n) Village: Gram Panchayat: Block Tahasil Post office Pin Code Mob No : ID Applicant s qualification:- 1. Educational Qualification:- SL No. Name of the Examination Name of the Board / University Division 2. Technical Qualification:- SL No. Name of the Course Name of the Board / University Division / Grade

3 4 3. Applicant s current profession: Business / Un-employed / others Infrastructure available 1 Number of Computer 2 Computer Peripheral 3 Furniture 4 Internet Connection (Broadband, 3G, 4G) 5 Internet Provider Computer Skill 1 Operation Skill/knowledge Internet browsing skill Experience in Years Knowledge of computers operation skill e-commerce (Banking, Online Purchase, Ticketing, Bill payment, etc.) Use of MS Office and similar applications 3 Purpose for which do you use a computer? Regular office work / business Educational Purposes Internet surfing / Games /

4 Others (please specify) Declarations: 1 Have you ever been convicted by any court of law for any criminal offence? 2 Is any criminal proceeding pending against you? 3 Have you at any time defaulted payments to any bank or financial institution? 4 Have you ever been involved/ charged in any fraud/corrupt/ misconduct / embezzlement/ misappropriation of any funds? I solemnly affirm that, the above information are true to the best of my knowledge and believe and no information has been concealed or misrepresented. In the event of any information found to be incorrect at any stage, the Competent Authority shall have the sole discretion to cancel the application/selection and forthwith terminate my agreement (if any) without prior notice. The competent Authority may initiate any other action permitted under law. Date : Place : Signature of the Applicant

5 Guidelines for Submission of Application Form:- 1. Applicant must be above 18 Years of age on the Date of Application. 2. Applicant must be a resident of the respective Gram Panchayat in Malkangiri district, for which he/she wants to apply. That G.Ps must have internet connectivity like Broadband, 3G or 4G. 3. The minimum educational qualification of the VLE is HSC/10 th pass having basic computer knowledge. 1 st preference will be given to women applicants. Additional preference will be given to the higher qualified applicants. For selection of VLE under CSC 2.0, preference will be given to the applicants belong to the same Gram Panchayat. In case of non availability of applicant from respective Gram Panchayat, then applicant of the nearby GP of the same Block will be considered. 4. Preference will be given to the applicant interested to open the CSC at Rajiv Gandhi Sewa Kendra or in any available place of G.P office. 5. Application must be filled up completely in all respects. 6. Applicant is required to affix two recent passport size color photograph on the application form. 7. Self attested copies of ID proof i.e. Pan Card / Voter ID Card / Aadhaar Card / Center Photos and Address Proof is required to be attached along with the application form. 8. Applicants must have to submit the location of CSC Center with Proper Latitude and longitude as well as recent colour photograph of front elevation where it is functioning or proposed to be function. 9. Self-attested copies of Educational Qualification Certificate, Certificate about Basic Computer Knowledge (Professional Qualification Certificate), Residence Certificate, Income certificate issued from competent authority should have to be furnished alongwith the application. 10. The outer envelope is to be superscripted with Application for Selection of VLE under CSC 2.0 Project for G.P. 11. The application form duly filled in all respect should reach by Registered Post/Speed Post only addressed to the Collector-cum- Chairman, DeGS, DeGS Cell, 02 nd Floor, Collectorate, Malkangiri. 12. The sealed application should reach the office of the Collectorate, Malkangiri on or before

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7 GP LIST ANNEXURE-I Sl.No. Name of the Block Name of the GP KORKUNDA 1 Chitapari-III 9 2 Dudameta 3 Old Chimitapalli 4 Tumusapalli 5 Mariwada 6 Nilakamberu 7 Korukonda 8 Somonathpur 9 Nakamamudi 2 Chitrakonda 17 1 Andrapalli 2 Panasput 3 Papermetla 4 Badaoada 5 Badapodar 6 Jodambo 7 Ralegada 8 Doraguda 9 Kopatuti 10 Gunthawada 11 Nuaguda 12 Tunnel Camp 13 Populur 14 Kurmanoor 15 Jantri 16 Dhuliput 17 Gajalmamudi 3 Khoirput 10 1 Andrahal 2 Kadamguda 3 Khoirput 4 Podaghat 5 Badadural 6 Madkapodar 7 Mudulipoda 8 Rasabeda 9 Kudumulugumma 10 Parkanmala

8 4 5 Mathili 17 Kalimela 22 1 Bhandaripangam 2 Udulibeda 3 Kamarpalli 4 Kartanpalli 5 Kianga 6 Salimi 7 Choulamendi 8 Kutunipalli 9 Dhungiaput 10 Temurupalli 11 Mahupadar 12 Pangam 13 Mecca 14 Kotapalli 15 Nayakguda 16 Bhejaguda 17 Chedenga 1 Badigeta 2 Gumuka 3 Koimetla 4 Tigal 5 Lugel 6 Kangurukonda 7 Venketpallam 8 Chintalwada 9 Chitgrangapalli 10 Telerai 11 Nalagunthi 12 Bhejengiwada 13 Gompakonda 14 Maharajpalli 15 Malavaram 16 Manyamkonda 17 Motu 18 Pusuguda 19 Tandabai 20 Bhubanpalli 21 Mandapalli 22 Badili

9 6 7 Malkangiri 18 Podia 8 1 Udupa 2 Gongala 3 Goudaguda 4 Jharapalli 5 Tamasa 6 Pandripani 7 Pedakonda 8 Pedawada 9 Biralaxmanpur 10 Markapalli 11 Sindhrimal 12 Serpalli 13 Challangua 14 Tondiki 15 Tondapalli 16 sikhpalli 17 Gorakhunta 18 Matapaka 1 Kaldapalli 2 Niliguda 3 Podia 4 Bapanpalli 5 Matteru 6 Semilibencha 7 Girkanpalli 8 Undrukonda