Head of FamilySecure Enrollment

MHIS Head of Family Request Form

Complete MHIS head of family details, attach the required documents, and forward the request to the SHA office workflow.

Sections
3
Category, applicant, spouse
Required uploads
2
EPIC front and back
Workflow
SHA
Pending office approval

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Category
Choose application type
Applicant
Add Aadhaar name
Location
Select district and block
Contact
Add mobile number
Use the same spelling as your EPIC and Aadhaar records to reduce verification delays.
A.
Category Details
Category
I would like to appear as
B.
Applicant Details
Please fill in the following details about yourself
Name as per Aadhaar (Mandatory) *
Father's/Mother's/Spouse Name
House number as per EPIC (Mandatory) *
Gender (Mandatory) *
Address as per EPIC (Mandatory) *
District (Mandatory) *
Name of block (Mandatory) *
Rural / Urban
Phone No *
Phone verification is temporarily disabled.
Pincode Number
Year of Birth
EPIC Number
Aadhaar Number
State Name
State Code
Upload EPIC front side *
Upload EPIC back side *
Upload Aadhaar