APPLICATION FOR REGISTRATION/ RENEWAL OF BUILDING AND OTHER CONSTRUCTION WORKER
“FORM XXVII”
[See Rule 265(1)]
1. (a) Name of the construction worker
: ………………………………………………………………………………..
Attach three
(b) Sex: ……………………………………………….(c) Marital Status:……………………………………………………….
Recent pass
(d) Father’s Name / Husband’s Name :………………………………………………………………………………….
Port size
Colour photo
(e) Date of Birth/Age (attested copies of proof of age to be enclosed):………………………………………
(f) Address:
Present address
Permanent address
Village:………………………………………………………………………
Village:………………………………………………………………………
Post Office:……………………………………………………………..
Police Station:……………………………………………………………
Gram Panchayat: ……………………………………………………..
Post Office:……………………………………………………………..
Block/Municipality / NAC: ………………………………………
Dist-…………………………………………………………………………
Gram Panchayat: ……………………………………………………..
2. Details of the family members
Sl. No.
Name
:
Police Station:……………………………………………………………
Block/Municipality / NAC: …………………………………………
Dist-…………………………………………………………………………..
Age
Sex
Relation with the applicant
3. Name & Address of the Establishment(s) where the applicant:……………………………………………………………………………..
worked during the last one year (With Registration No. if Available).
4. Date of working with duration of work in the establishment(s): ………………………………………………………………………………
5. Nature of Job :…………………………………… 6. Educational Qualification / Training details. If any :……………………………….
7. Whether APL/BPL/ Antyodaya/ Others Mention Card No. : (Enclose proof in support of it)
(Based on self declaration by the applicant) ……………………………………………………………………
8. PF/ESI No., if any: …………………………………… 9. (i) Whether SC/ST/SEBC: ………………………………………………………………..
(ii) Minority /Physically Challenged/etc. (Enclose proof in support of it): 10. Migrant Labour: Yes
No
(Based on self declaration by the applicant)………………………………………………………………………………………………
11. Bank account No. / Name & Address of Branch & IFSC Code (Enclose proof in support of it): ....................................................................
.............................................................................................................................................................................
The above facts are true to the best of my knowledge and information .
Place:………………………………………………
Date:………………………………………………
Signature/Thumb impression of the Applicant
Certified that the above applicant is/was engaged by me/known to me as a building workers
since ………………………………
Signature of the Employer/Registered union
with seal, address & contact no.
.…………………………………………………………………………………………………………………………………………………………………………………..
Acknowledgement
Received the application for registration under B.O.C.W (R.E & C.S) Act, 1996 From Sri/ Smt. ....................................
…………………...An amount of Rs. ……………………… as registration & one years’ membership fee has been receipt vide
Money receipt No. ………………………………. dated ……………………….
Signature :
Date ………………………………………
SELF DECLARATION BY APPLICANT
I Sri/ Smt. …………………………………………………………………………………………………………………………
S/D/W of ……………………………………………………………………………………………………………………… of
Village …………………………………………………………………… Po. …………………………………………………
Ps. ……………………………………………………………………….Dist ……………………………………………………
Do hereby solemnly declare.
i)
That, I have not been enrolled my name in any other district / state as beneficiary
under Building & Other Construction Workers’ (RE & CS) Rule 2002.
ii)
That, I am not a member of any of the Welfare fund established under any law for
the time being in force (U/S 264 of OB & OCW (RE & CS)) Rule 2002.
iii)
That, I am a BPL/Antyodaya/Non-BPL card holder.
iv)
That, I belong to SC/ST/SEBC/General/Minority/Physical challenged/etc. category.
This submissions made above are true to the best of my knowledge and belief.
Signature/Thumb impression of the Applicant
CERTIFICATE OF EMPLOYMENT PROOF
[ U/s 265(2) (iii) OF OB & OCW (RE & CS) Rule-2002]
TO WHOM IT MAY CONCERN
This is to certify that the applicant namely Sri/ Smt.: ……………………………………………………………………….
S/ D/ W/ of ………………………………………………………………….. of Village: …………………………………………………………
Po : …………………………………………… Ps : ………………………………… G.P/NAC/Municipality: ………………………………
Block: ………………………………………. Dist: ………………………………… is a construction worker ( …………………………)
by occupation and has subscribed his/her name as a member of Trade Union namely ………………………………...
since the year ………………………….. The Trade Union U/S 265(2) (iii) OF OB & OCW (RE & CS) Rule-2002, do
hereby declare that the worker has worked under different employers in different months of the year as
specified below.
Work Report of the Worker for the Year……………………
Sl
No.
Name , Address & Regd. No of
Employer
Period of Employment
Total Days
Employed
Amount of Daily
wages.
1
2
3
4
5
6
Signature/Thumb impression of the Applicant
Signature of the Authorized Person
With Seal & Stamp.
Regd. No.ORI-KHU………………….
Date:……………………………………….
APPLICATION FOR REGISTRATION AS A BENEFICIARY UNDER BUILDING AND OTHER
CONSTRUCTION WORKERS (R.E & C.S.) ACT, 1996
Sri/Smt………………………………………………………………………………………………………………………………………………………………………………….
D.L.O.
Page 1 to ____/C. may kindly be seen.
One Sri/Smt………………………………………
has applied and submitted the following
documents for Registration of his/her name as
Building & Other Construction Worker
(beneficiary) under the provision of
Building and Other Construction Workers
(R.E & C.S.) Act, 1996.
1.
2.
3.
4.
Application in Form No. XXVII
3 no’s of photograph.
Nomination form.
Original money receipt of Rs.20/Vide receipt No……………….. dt…………..
5. Annual subscription.
6. Copy of age certificate.
7. Certificate of employment issued by the employer./Certificate of Registered Trade
Union./Certificate of Inspector an affidavit to that effect by the worker.
8. RSBY Form
9. Photo Copy of the fist page of Bank Pass Book .
10. APL/BPL/ Antyodaya/ Others Mention Card No. : (Enclose proof in support of it)
We may register his/her name as beneficiary under the aforesaid Board.
Submitted for kind order.