Student  for COVID-19 Vaccination
Purba Bardhaman
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Block  or Municipality Name where College or University located *
GP  Name or Ward No where College or University located *
PIN  Code *
(College or University  PIN)
Name of the Student *
Department *
Category *
Name of College or University *
Year of Birth *
Gender *
Mobile *
Student ID No. (University or College ID Nos.) *
ID Type (AADHAAR/PAN/EPIC etc) *
ID Number (AADHAAR/PAN/EPIC/DL/Other) *
1st Dose/2nd Dose *
If 2nd dose Yes then Date of 1st Dose
MM
/
DD
/
YYYY
If 2nd dose Yes then Type of Vaccine(Covaxin / Covishield)
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