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Name of the Organisation*:

Url of the Organisation portal,if any (http://)

Address of the Organization

Address line 1*:

Address line 2

City*:

State*:

Select State Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhatisgarh Dadra and Nagar Haveli Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttaranchal Uttar Pradesh West Bengal

Postal/Zip Code*:

Official Phone Number*:

Details of the Authorised Signatory

Name*:

Designation*:

Email Address*:

(Note*: This email address would act as a login ID and also be used in further communications)

Mobile No.*:

Account Information

Username*:

Password*:

Re-type password*:

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