Asociate Registration Form For Chattisgarh
 Center Details
* Center Name / Shop Name *Center Code
*Center / Shop Address
 Login Details
*Username
*can not be changed Later
 *Email
*Password *Confirm Password
 Personal Details
*First Name *Last Name
*Address *District
City
Village
Pincode Phone no
Country Code Area Code Phone Number
*Mobile *Pan No
*Attach PAN Card Copy :
(Pan Card Image Once Saved can't be changed) 		*Attach Address Proof
(Address Proof must be upload for verification)

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