2. Details of the family members
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.
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