TB Mukt Bharat

Nikshay Mitra Enrolment Form

1. Basic Details of Nikshay Mitra

Name of Mitra / Organization

Mobile Number

Email ID

Address

State

District

2. Commitment & Type of Support

Nature of Support to be Provided

Nutritional Support (Food Basket)

Minimum Duration of Support

6 Months (Minimum)

1 Year

2 Years

3 Years

3. Geographical Area of Support & Patient Allocation

Select one or more districts in Manipur you wish to support, and specify the number of patients for each selected district:

4. Declaration & Privacy Undertaking

I/We hereby declare that the details provided above are true and correct. I/We commit to providing continuous, quality services to the supported TB beneficiaries for the specified duration. I/We explicitly undertake that I/We shall not use beneficiary data or diagnostic information for any purpose outside the official 'Community Support to TB Patients - Nikshay Mitra' framework, nor disclose patient identities to any external identity or unauthorized organization.

I / We accept the above official declaration & privacy undertaking.