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COVID-19 Vaccine Registration Form
Together India will defeat COVID-19
(साथ मिलकर भारत COVID-19 को हरा देगा)
Name
*
( नाम )
Email
*
( ईमेल )
Mobile No.
*
( मोबाइल नंबर )
Appointment Date
*
( नियुक्ति तिथि )
Appointment Time
*
( नियुक्ति का समय )
Vaccine Center Details
*
( टीका केंद्र विवरण )
Date of Birth
*
( जन्म की तारीख )
Address
*
( पता )
Gender
*
( लिंग )
Male
Female
Marital Status
*
( वैवाहिक स्थिति )
Single
Married
Divorced
Country
*
( देश )
India
State
*
( राज्य )
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Goa
Gujarat
Haryana
Himachal Pradesh
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
PinCode
*
( पिन कोड )