{"id":5329,"date":"2026-07-18T06:48:45","date_gmt":"2026-07-18T06:48:45","guid":{"rendered":"https:\/\/birct.in\/?page_id=5329"},"modified":"2026-07-18T07:03:50","modified_gmt":"2026-07-18T07:03:50","slug":"join-form","status":"publish","type":"page","link":"https:\/\/birct.in\/index.php\/join-form\/","title":{"rendered":"Join Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5329\" class=\"elementor elementor-5329\">\n\t\t\t\t<div class=\"elementor-element elementor-element-77e1d99e e-flex e-con-boxed e-con e-parent\" data-id=\"77e1d99e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5a712ca6 elementor-widget elementor-widget-text-editor\" data-id=\"5a712ca6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<div class=\"ngomr-wrap\">\n<div class=\"ngomr-header\">\n<h2 class=\"ngomr-title\">\u0938\u0926\u0938\u094d\u092f\u0924\u093e \u092a\u0902\u091c\u0940\u0915\u0930\u0923<\/h2>\n<\/p><\/div>\n<div class=\"ngomr-media\">\n<figure class=\"ngomr-media__qr\">\n\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"300\" height=\"300\" src=\"https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-300x300.jpeg\" class=\"attachment-medium size-medium\" alt=\"Payment QR code\" srcset=\"https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-300x300.jpeg 300w, https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-150x150.jpeg 150w, https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-70x70.jpeg 70w, https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-212x212.jpeg 212w, https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-100x100.jpeg 100w, https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53-460x460.jpeg 460w, https:\/\/birct.in\/wp-content\/uploads\/ngo-receipts\/2026\/07\/WhatsApp-Image-2026-07-17-at-12.57.53.jpeg 512w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><figcaption>\n\t\t\t\t\t\t\t<strong>\u092d\u0941\u0917\u0924\u093e\u0928 \u0939\u0947\u0924\u0941 \u0938\u094d\u0915\u0948\u0928 \u0915\u0930\u0947\u0902<\/strong><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"ngomr-upi\">krishna@okxs<\/span><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<small>\u092a\u0939\u0932\u0947 \u092d\u0941\u0917\u0924\u093e\u0928 \u0915\u0930\u0947\u0902, \u092b\u093f\u0930 \u0928\u0940\u091a\u0947 \u091f\u094d\u0930\u093e\u0902\u091c\u093c\u0948\u0915\u094d\u0936\u0928 \u0906\u0908\u0921\u0940 \u092d\u0930\u0947\u0902 \u0914\u0930 \u0930\u0938\u0940\u0926 \u0905\u092a\u0932\u094b\u0921 \u0915\u0930\u0947\u0902\u0964<\/small><br \/>\n\t\t\t\t\t\t<\/figcaption><\/figure>\n<\/p><\/div>\n<form class=\"ngomr-form\" method=\"post\" enctype=\"multipart\/form-data\" novalidate>\n\t\t\t<input type=\"hidden\" id=\"ngomr_nonce\" name=\"ngomr_nonce\" value=\"c7c132ff11\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/5329\" \/>\t\t\t<input type=\"hidden\" name=\"ngomr_submit\" value=\"1\"><\/p>\n<p class=\"ngomr-hp\" aria-hidden=\"true\">\n\t\t\t\t<label>Leave this field empty\t\t\t\t\t<input type=\"text\" name=\"ngomr_website\" value=\"\" tabindex=\"-1\" autocomplete=\"off\"><br \/>\n\t\t\t\t<\/label>\n\t\t\t<\/p>\n<fieldset class=\"ngomr-fieldset\">\n<legend>\u0935\u094d\u092f\u0915\u094d\u0924\u093f\u0917\u0924 \u0935\u093f\u0935\u0930\u0923<\/legend>\n<div class=\"ngomr-grid\">\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-name\"><br \/>\n\t\t\t\t\t\t\t\t\u0928\u093e\u092e\t\t\t\t\t\t\t\t<span class=\"req\">*<\/span>\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\tid=\"ngomr-name\"\n\t\t\t\t\t\t\t\tname=\"ngomr_name\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\t\t\t\t\t\t\t\tautocomplete=\"name\"\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<small class=\"ngomr-hint\">\u0906\u0927\u093e\u0930 \u0915\u093e\u0930\u094d\u0921 \u0915\u0947 \u0905\u0928\u0941\u0938\u093e\u0930<\/small>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-aadhar_number\"><br \/>\n\t\t\t\t\t\t\t\t\u0906\u0927\u093e\u0930 \u0915\u093e\u0930\u094d\u0921 \u0928\u0902\u092c\u0930\t\t\t\t\t\t\t\t<span class=\"req\">*<\/span>\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\tid=\"ngomr-aadhar_number\"\n\t\t\t\t\t\t\t\tname=\"ngomr_aadhar_number\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tinputmode=\"numeric\" maxlength=\"12\" pattern=\"[0-9]{12}\"\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-father_name\"><br \/>\n\t\t\t\t\t\t\t\t\u092a\u093f\u0924\u093e\/\u092a\u0924\u093f \u0915\u093e \u0928\u093e\u092e\t\t\t\t\t\t\t\t<span class=\"req\">*<\/span>\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\tid=\"ngomr-father_name\"\n\t\t\t\t\t\t\t\tname=\"ngomr_father_name\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-dob\"><br \/>\n\t\t\t\t\t\t\t\t\u091c\u0928\u094d\u092e \u0924\u093f\u0925\u093f\t\t\t\t\t\t\t\t<span class=\"req\">*<\/span>\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"date\"\n\t\t\t\t\t\t\t\tid=\"ngomr-dob\"\n\t\t\t\t\t\t\t\tname=\"ngomr_dob\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<small class=\"ngomr-hint\">\u0906\u0927\u093e\u0930 \u0915\u093e\u0930\u094d\u0921 \u0915\u0947 \u0905\u0928\u0941\u0938\u093e\u0930<\/small>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-mobile\"><br \/>\n\t\t\t\t\t\t\t\t\u092e\u094b\u092c\u093e\u0907\u0932 \u0928\u0902\u092c\u0930\t\t\t\t\t\t\t\t<span class=\"req\">*<\/span>\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"tel\"\n\t\t\t\t\t\t\t\tid=\"ngomr-mobile\"\n\t\t\t\t\t\t\t\tname=\"ngomr_mobile\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tinputmode=\"numeric\" maxlength=\"10\" pattern=\"[0-9]{10}\"\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-gender\">\u091c\u0947\u0902\u0921\u0930 <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<select id=\"ngomr-gender\" name=\"ngomr_gender\" required><option value=\"\">\u091a\u0941\u0928\u0947\u0902\u2026<\/option><option value=\"Male\" ><br \/>\n\t\t\t\t\t\t\t\t\tMale\t\t\t\t\t\t\t\t<\/option><option value=\"Female\" ><br \/>\n\t\t\t\t\t\t\t\t\tFemale\t\t\t\t\t\t\t\t<\/option><option value=\"Other\" ><br \/>\n\t\t\t\t\t\t\t\t\tOther\t\t\t\t\t\t\t\t<\/option><\/select>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<\/fieldset>\n<fieldset class=\"ngomr-fieldset\">\n<legend>\u0935\u094d\u092f\u0935\u0938\u093e\u092f<\/legend>\n<div class=\"ngomr-field\">\n\t\t\t\t\t<span class=\"ngomr-label\">\u0935\u094d\u092f\u0935\u0938\u093e\u092f <span class=\"req\">*<\/span><\/span><\/p>\n<div class=\"ngomr-radios\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Government Job\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Government Job<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Private Job\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Private Job<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Business\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Business<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Agriculture\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Agriculture<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Housewife\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Housewife<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Student\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Student<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Contract Workers\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Contract Workers<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<label class=\"ngomr-radio\"><br \/>\n\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\t\ttype=\"radio\"\n\t\t\t\t\t\t\t\t\tname=\"ngomr_occupation\"\n\t\t\t\t\t\t\t\t\tvalue=\"Public Representative\"\n\t\t\t\t\t\t\t\t\tdata-ngomr-occupation\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t><br \/>\n\t\t\t\t\t\t\t\t<span>Public Representative<\/span><br \/>\n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<div class=\"ngomr-grid\">\n<div class=\"ngomr-field\" id=\"ngomr-department-wrap\" hidden>\n\t\t\t\t\t\t<label for=\"ngomr-department\">\u0935\u093f\u092d\u093e\u0917 <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<select id=\"ngomr-department\" name=\"ngomr_department\" data-selected=\"\"><option value=\"\">\u0935\u093f\u092d\u093e\u0917 \u091a\u0941\u0928\u0947\u0902<\/option><\/select>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field ngomr-field--wide\">\n\t\t\t\t\t\t<label for=\"ngomr-working_office\">\u0915\u093e\u0930\u094d\u092f\u0930\u0924 \u0915\u093e\u0930\u094d\u092f\u093e\u0932\u092f\/\u0915\u0902\u092a\u0928\u0940\/\u0926\u0941\u0915\u093e\u0928\/\u092a\u094d\u0930\u0924\u093f\u0937\u094d\u0920\u093e\u0928 \u0915\u093e \u0928\u093e\u092e \u0935 \u092a\u0924\u093e <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<input type=\"text\" id=\"ngomr-working_office\" name=\"ngomr_working_office\" value=\"\" required>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<\/fieldset>\n<fieldset class=\"ngomr-fieldset\">\n<legend>\u092a\u0924\u093e<\/legend>\n<div class=\"ngomr-grid\">\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-state\">\u0930\u093e\u091c\u094d\u092f <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<select id=\"ngomr-state\" name=\"ngomr_state\" required><option value=\"Uttar Pradesh\"  selected='selected'><br \/>\n\t\t\t\t\t\t\t\t\tUttar Pradesh\t\t\t\t\t\t\t\t<\/option><\/select>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-district\">\u0938\u094d\u0925\u093e\u0908 \u0928\u093f\u0935\u093e\u0938\u0940 \u091c\u093f\u0932\u093e <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<select id=\"ngomr-district\" name=\"ngomr_district\" required data-ngomr-district><option value=\"\">\u091c\u093f\u0932\u093e \u091a\u0941\u0928\u0947\u0902<\/option><option value=\"Agra\" ><br \/>\n\t\t\t\t\t\t\t\t\tAgra\t\t\t\t\t\t\t\t<\/option><option value=\"Aligarh\" ><br \/>\n\t\t\t\t\t\t\t\t\tAligarh\t\t\t\t\t\t\t\t<\/option><option value=\"Ambedkar Nagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tAmbedkar Nagar\t\t\t\t\t\t\t\t<\/option><option value=\"Amethi\" ><br \/>\n\t\t\t\t\t\t\t\t\tAmethi\t\t\t\t\t\t\t\t<\/option><option value=\"Amroha\" ><br \/>\n\t\t\t\t\t\t\t\t\tAmroha\t\t\t\t\t\t\t\t<\/option><option value=\"Auraiya\" ><br \/>\n\t\t\t\t\t\t\t\t\tAuraiya\t\t\t\t\t\t\t\t<\/option><option value=\"Ayodhya\" ><br \/>\n\t\t\t\t\t\t\t\t\tAyodhya\t\t\t\t\t\t\t\t<\/option><option value=\"Azamgarh\" ><br \/>\n\t\t\t\t\t\t\t\t\tAzamgarh\t\t\t\t\t\t\t\t<\/option><option value=\"Baghpat\" ><br \/>\n\t\t\t\t\t\t\t\t\tBaghpat\t\t\t\t\t\t\t\t<\/option><option value=\"Ballia\" ><br \/>\n\t\t\t\t\t\t\t\t\tBallia\t\t\t\t\t\t\t\t<\/option><option value=\"Balrampur\" ><br \/>\n\t\t\t\t\t\t\t\t\tBalrampur\t\t\t\t\t\t\t\t<\/option><option value=\"Banda\" ><br \/>\n\t\t\t\t\t\t\t\t\tBanda\t\t\t\t\t\t\t\t<\/option><option value=\"Barabanki\" ><br \/>\n\t\t\t\t\t\t\t\t\tBarabanki\t\t\t\t\t\t\t\t<\/option><option value=\"Bareilly\" ><br \/>\n\t\t\t\t\t\t\t\t\tBareilly\t\t\t\t\t\t\t\t<\/option><option value=\"Basti\" ><br \/>\n\t\t\t\t\t\t\t\t\tBasti\t\t\t\t\t\t\t\t<\/option><option value=\"Bahraich\" ><br \/>\n\t\t\t\t\t\t\t\t\tBahraich\t\t\t\t\t\t\t\t<\/option><option value=\"Bijnor\" ><br \/>\n\t\t\t\t\t\t\t\t\tBijnor\t\t\t\t\t\t\t\t<\/option><option value=\"Budaun\" ><br \/>\n\t\t\t\t\t\t\t\t\tBudaun\t\t\t\t\t\t\t\t<\/option><option value=\"Bulandshahr\" ><br \/>\n\t\t\t\t\t\t\t\t\tBulandshahr\t\t\t\t\t\t\t\t<\/option><option value=\"Chandauli\" ><br \/>\n\t\t\t\t\t\t\t\t\tChandauli\t\t\t\t\t\t\t\t<\/option><option value=\"Chitrakoot\" ><br \/>\n\t\t\t\t\t\t\t\t\tChitrakoot\t\t\t\t\t\t\t\t<\/option><option value=\"Deoria\" ><br \/>\n\t\t\t\t\t\t\t\t\tDeoria\t\t\t\t\t\t\t\t<\/option><option value=\"Etah\" ><br \/>\n\t\t\t\t\t\t\t\t\tEtah\t\t\t\t\t\t\t\t<\/option><option value=\"Etawah\" ><br \/>\n\t\t\t\t\t\t\t\t\tEtawah\t\t\t\t\t\t\t\t<\/option><option value=\"Farrukhabad\" ><br \/>\n\t\t\t\t\t\t\t\t\tFarrukhabad\t\t\t\t\t\t\t\t<\/option><option value=\"Fatehpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tFatehpur\t\t\t\t\t\t\t\t<\/option><option value=\"Firozabad\" ><br \/>\n\t\t\t\t\t\t\t\t\tFirozabad\t\t\t\t\t\t\t\t<\/option><option value=\"Gautam Buddha Nagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tGautam Buddha Nagar\t\t\t\t\t\t\t\t<\/option><option value=\"Ghaziabad\" ><br \/>\n\t\t\t\t\t\t\t\t\tGhaziabad\t\t\t\t\t\t\t\t<\/option><option value=\"Ghazipur\" ><br \/>\n\t\t\t\t\t\t\t\t\tGhazipur\t\t\t\t\t\t\t\t<\/option><option value=\"Gonda\" ><br \/>\n\t\t\t\t\t\t\t\t\tGonda\t\t\t\t\t\t\t\t<\/option><option value=\"Gorakhpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tGorakhpur\t\t\t\t\t\t\t\t<\/option><option value=\"Hamirpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tHamirpur\t\t\t\t\t\t\t\t<\/option><option value=\"Hapur\" ><br \/>\n\t\t\t\t\t\t\t\t\tHapur\t\t\t\t\t\t\t\t<\/option><option value=\"Hardoi\" ><br \/>\n\t\t\t\t\t\t\t\t\tHardoi\t\t\t\t\t\t\t\t<\/option><option value=\"Hathras\" ><br \/>\n\t\t\t\t\t\t\t\t\tHathras\t\t\t\t\t\t\t\t<\/option><option value=\"Jalaun\" ><br \/>\n\t\t\t\t\t\t\t\t\tJalaun\t\t\t\t\t\t\t\t<\/option><option value=\"Jaunpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tJaunpur\t\t\t\t\t\t\t\t<\/option><option value=\"Jhansi\" ><br \/>\n\t\t\t\t\t\t\t\t\tJhansi\t\t\t\t\t\t\t\t<\/option><option value=\"Kannauj\" ><br \/>\n\t\t\t\t\t\t\t\t\tKannauj\t\t\t\t\t\t\t\t<\/option><option value=\"Kanpur Dehat\" ><br \/>\n\t\t\t\t\t\t\t\t\tKanpur Dehat\t\t\t\t\t\t\t\t<\/option><option value=\"Kanpur Nagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tKanpur Nagar\t\t\t\t\t\t\t\t<\/option><option value=\"Kasganj\" ><br \/>\n\t\t\t\t\t\t\t\t\tKasganj\t\t\t\t\t\t\t\t<\/option><option value=\"Kaushambi\" ><br \/>\n\t\t\t\t\t\t\t\t\tKaushambi\t\t\t\t\t\t\t\t<\/option><option value=\"Kushinagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tKushinagar\t\t\t\t\t\t\t\t<\/option><option value=\"Lakhimpur Kheri\" ><br \/>\n\t\t\t\t\t\t\t\t\tLakhimpur Kheri\t\t\t\t\t\t\t\t<\/option><option value=\"Lalitpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tLalitpur\t\t\t\t\t\t\t\t<\/option><option value=\"Lucknow\" ><br \/>\n\t\t\t\t\t\t\t\t\tLucknow\t\t\t\t\t\t\t\t<\/option><option value=\"Maharajganj\" ><br \/>\n\t\t\t\t\t\t\t\t\tMaharajganj\t\t\t\t\t\t\t\t<\/option><option value=\"Mahoba\" ><br \/>\n\t\t\t\t\t\t\t\t\tMahoba\t\t\t\t\t\t\t\t<\/option><option value=\"Mainpuri\" ><br \/>\n\t\t\t\t\t\t\t\t\tMainpuri\t\t\t\t\t\t\t\t<\/option><option value=\"Mathura\" ><br \/>\n\t\t\t\t\t\t\t\t\tMathura\t\t\t\t\t\t\t\t<\/option><option value=\"Mau\" ><br \/>\n\t\t\t\t\t\t\t\t\tMau\t\t\t\t\t\t\t\t<\/option><option value=\"Meerut\" ><br \/>\n\t\t\t\t\t\t\t\t\tMeerut\t\t\t\t\t\t\t\t<\/option><option value=\"Mirzapur\" ><br \/>\n\t\t\t\t\t\t\t\t\tMirzapur\t\t\t\t\t\t\t\t<\/option><option value=\"Moradabad\" ><br \/>\n\t\t\t\t\t\t\t\t\tMoradabad\t\t\t\t\t\t\t\t<\/option><option value=\"Muzaffarnagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tMuzaffarnagar\t\t\t\t\t\t\t\t<\/option><option value=\"Pilibhit\" ><br \/>\n\t\t\t\t\t\t\t\t\tPilibhit\t\t\t\t\t\t\t\t<\/option><option value=\"Pratapgarh\" ><br \/>\n\t\t\t\t\t\t\t\t\tPratapgarh\t\t\t\t\t\t\t\t<\/option><option value=\"Prayagraj\" ><br \/>\n\t\t\t\t\t\t\t\t\tPrayagraj\t\t\t\t\t\t\t\t<\/option><option value=\"Raebareli\" ><br \/>\n\t\t\t\t\t\t\t\t\tRaebareli\t\t\t\t\t\t\t\t<\/option><option value=\"Rampur\" ><br \/>\n\t\t\t\t\t\t\t\t\tRampur\t\t\t\t\t\t\t\t<\/option><option value=\"Saharanpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tSaharanpur\t\t\t\t\t\t\t\t<\/option><option value=\"Sambhal\" ><br \/>\n\t\t\t\t\t\t\t\t\tSambhal\t\t\t\t\t\t\t\t<\/option><option value=\"Sant Kabir Nagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tSant Kabir Nagar\t\t\t\t\t\t\t\t<\/option><option value=\"Sant Ravidass Nagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tSant Ravidass Nagar\t\t\t\t\t\t\t\t<\/option><option value=\"Shahjahanpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tShahjahanpur\t\t\t\t\t\t\t\t<\/option><option value=\"Shamli\" ><br \/>\n\t\t\t\t\t\t\t\t\tShamli\t\t\t\t\t\t\t\t<\/option><option value=\"Shravasti\" ><br \/>\n\t\t\t\t\t\t\t\t\tShravasti\t\t\t\t\t\t\t\t<\/option><option value=\"Siddharthnagar\" ><br \/>\n\t\t\t\t\t\t\t\t\tSiddharthnagar\t\t\t\t\t\t\t\t<\/option><option value=\"Sitapur\" ><br \/>\n\t\t\t\t\t\t\t\t\tSitapur\t\t\t\t\t\t\t\t<\/option><option value=\"Sonbhadra\" ><br \/>\n\t\t\t\t\t\t\t\t\tSonbhadra\t\t\t\t\t\t\t\t<\/option><option value=\"Sultanpur\" ><br \/>\n\t\t\t\t\t\t\t\t\tSultanpur\t\t\t\t\t\t\t\t<\/option><option value=\"Unnao\" ><br \/>\n\t\t\t\t\t\t\t\t\tUnnao\t\t\t\t\t\t\t\t<\/option><option value=\"Varanasi\" ><br \/>\n\t\t\t\t\t\t\t\t\tVaranasi\t\t\t\t\t\t\t\t<\/option><\/select>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-block\">\u0938\u094d\u0925\u093e\u0908 \u0928\u093f\u0935\u093e\u0938\u0940 \u092c\u094d\u0932\u0949\u0915 <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<select id=\"ngomr-block\" name=\"ngomr_block\" required data-ngomr-block data-selected=\"\"><option value=\"\">\u092c\u094d\u0932\u0949\u0915 \u091a\u0941\u0928\u0947\u0902<\/option><\/select>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-email\">\u0908\u092e\u0947\u0932 (\u0935\u0948\u0915\u0932\u094d\u092a\u093f\u0915)<\/label><br \/>\n\t\t\t\t\t\t<input type=\"email\" id=\"ngomr-email\" name=\"ngomr_email\" value=\"\" autocomplete=\"email\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field ngomr-field--full\">\n\t\t\t\t\t\t<label for=\"ngomr-perm_address\">\u0938\u094d\u0925\u093e\u0908 \u092a\u0924\u093e <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<textarea id=\"ngomr-perm_address\" name=\"ngomr_perm_address\" rows=\"3\" required><\/textarea>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<\/fieldset>\n<fieldset class=\"ngomr-fieldset\">\n<legend>\u0928\u0949\u092e\u093f\u0928\u0940<\/legend>\n<div class=\"ngomr-grid\">\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-nominee_name\"><br \/>\n\t\t\t\t\t\t\t\t\u0928\u0949\u092e\u093f\u0928\u0940 \u0915\u093e \u0928\u093e\u092e <span class=\"req\">*<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\tid=\"ngomr-nominee_name\"\n\t\t\t\t\t\t\t\tname=\"ngomr_nominee_name\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-nominee_relationship\"><br \/>\n\t\t\t\t\t\t\t\t\u0928\u0949\u092e\u093f\u0928\u0940 \u0938\u0947 \u0938\u0902\u092c\u0902\u0927 <span class=\"req\">*<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"text\"\n\t\t\t\t\t\t\t\tid=\"ngomr-nominee_relationship\"\n\t\t\t\t\t\t\t\tname=\"ngomr_nominee_relationship\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t\t<label for=\"ngomr-nominee_number\"><br \/>\n\t\t\t\t\t\t\t\t\u0928\u0949\u092e\u093f\u0928\u0940 \u0915\u093e \u092e\u094b\u092c\u093e\u0907\u0932 \u0928\u0902\u092c\u0930 <span class=\"req\">*<\/span><br \/>\n\t\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\t\ttype=\"tel\"\n\t\t\t\t\t\t\t\tid=\"ngomr-nominee_number\"\n\t\t\t\t\t\t\t\tname=\"ngomr_nominee_number\"\n\t\t\t\t\t\t\t\tvalue=\"\"\n\t\t\t\t\t\t\t\trequired\n\t\t\t\t\t\t\t\tinputmode=\"numeric\" maxlength=\"10\" pattern=\"[0-9]{10}\"\t\t\t\t\t\t\t>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<\/fieldset>\n<fieldset class=\"ngomr-fieldset\">\n<legend>\u092d\u0941\u0917\u0924\u093e\u0928<\/legend>\n<div class=\"ngomr-grid\">\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-transaction_id\">\u091f\u094d\u0930\u093e\u0902\u091c\u093c\u0948\u0915\u094d\u0936\u0928 \u0906\u0908\u0921\u0940 <span class=\"req\">*<\/span><\/label><br \/>\n\t\t\t\t\t\t<input type=\"text\" id=\"ngomr-transaction_id\" name=\"ngomr_transaction_id\" value=\"\" required>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field\">\n\t\t\t\t\t\t<label for=\"ngomr-referred_by\">\u0930\u0947\u092b\u0930 \u0915\u094b\u0921 (\u0935\u0948\u0915\u0932\u094d\u092a\u093f\u0915)<\/label><br \/>\n\t\t\t\t\t\t<input type=\"text\" id=\"ngomr-referred_by\" name=\"ngomr_referred_by\" value=\"\" maxlength=\"10\" inputmode=\"numeric\" pattern=\"[0-9]{10}\"><br \/>\n\t\t\t\t\t\t<small class=\"ngomr-hint\">\u0930\u0947\u092b\u0930 \u0915\u0930\u0928\u0947 \u0935\u093e\u0932\u0947 \u0915\u0940 10 \u0905\u0902\u0915\u094b\u0902 \u0915\u0940 \u092f\u0942\u0928\u093f\u0915 \u0906\u0908\u0921\u0940<\/small>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<div class=\"ngomr-field ngomr-field--full\">\n\t\t\t\t\t\t<label for=\"ngomr-receipt\"><br \/>\n\t\t\t\t\t\t\t\u091f\u094d\u0930\u0938\u094d\u091f \u0915\u094b &#8377; \u0915\u093e \u0926\u093e\u0928 \u2014 \u092d\u0941\u0917\u0924\u093e\u0928 \u0930\u0938\u0940\u0926 \u0905\u092a\u0932\u094b\u0921 \u0915\u0930\u0947\u0902\t\t\t\t\t\t\t<span class=\"req\">*<\/span><br \/>\n\t\t\t\t\t\t<\/label><br \/>\n\t\t\t\t\t\t<input type=\"file\" id=\"ngomr-receipt\" name=\"ngomr_payment_receipt_upload\" accept=\"image\/jpeg,image\/png,image\/gif,application\/pdf\" required><br \/>\n\t\t\t\t\t\t<small class=\"ngomr-hint\">JPG, PNG, GIF \u092f\u093e PDF, \u0905\u0927\u093f\u0915\u0924\u092e 5 MB<\/small>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<\/fieldset>\n<div class=\"ngomr-field\">\n\t\t\t\t<label class=\"ngomr-check\"><br \/>\n\t\t\t\t\t<input type=\"checkbox\" name=\"ngomr_announcement\" value=\"1\" required><br \/>\n\t\t\t\t\t<span>I have read the Rules and Regulations of BIRCT team available on the Website. I agree to all the  terms and conditionons. 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