COVID - 19 VACCINATION FORM
QUEEN'S NECKLACE AND MUMBAI ZONE
Name as per Aadhar card
*
First Name
Middle Name
Last Name
Are you a JITO Member ?
*
YES
NO
Unique Identification (UID)
*
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
Are you Connected With Any JAIN ORGANIZATION?
Date of Birth in DD/MM/YY
*
-
Day
-
Month
Year
Date
Sex
Male
Female
Contact Number
*
Vaccine Details
1st Dose
2nd Dose
Identification Proof ( Pan Card, Work ID , Other)
*
Browse Files
Cancel
of
Aadhar Card
Browse Files
Cancel
of
Covin Ref ID
Any Allergy (Specify)
Any Chronic Diseases (Specify)
Any Other Symptoms (Cough/Cold/Fever/Loss of smell etc).
Payment Refrence ID
*
Payment Done By
Paytm
Google Pay
Net Banking
BHIM UPI
Submit
Should be Empty: