Revised Form - C

NATINSURE MUTUAL BENEFIT SOCIETY

C/o National Insurance Company Limited
3, Middl eton Street, Annexe Building, Kolkata 700 071

APPLICATION FOR AWARDS TO CHILDREN OF MEMBERS

1. 2.









3.





4. Particulars of the Child (Awardee as per NMBS Scheme):-

5. Whether the member applied earlier for Award in same academic year
(Put tick Mark in appropriate box):-

6. Choice of Article:-
(As per list of Articles approved by NMBS for the purpose of awarding the child in accordance to his/her entitlement)

1
st
Preference Item Code No.

2
rd
Preference Item Code No.

7. Documents enclosed (Put Tick Mark in appropriate boxes):-


8.




9. NMBS Subscription Deduction Certificate (to be completed by Accounts Dept. of concerned D.O./R.O./H.O. only)

Certified that last deduction of NMBS subscription amounting Rs. _______ (Rupees___________________________________)
was made from the salary of the member for the month of _____________year_________.

This is also certified that there is no interruption in deduction of NMBS subscription from the salary of the member concerned
since his/her joining the present office /society.

Date :

SIGNATURE OF THE
AUTHORISED OFFICER* WITH SEAL
*Any Class I Officer of H.O. Accounts Dept./Regional Accountant/Regional Accounts Officer/Divisional Manager/Divisional Accounts Officer
Guidelines for the Members:-
1. Award is admissible only on securing 75% and above Marks in SSC/HSC/Graduation Level Final Examination conducted by
recognized Boards/Universities as per revised scheme.
2. If for administrative reason the Society is unable to provide the award in kinds then cash award as per the entitlement of the
awardee may be sanctioned.
3. Applications received after expiry of three months from the date of publication of result will not be entertained.

FOR THE USE OF THE SANCTIONING AUTHORITY


Name of the Article sanctioned Item Code No.

Date: _________________
Processed By: Verified By: Sanctioned By:


Name of the Child
Age
(Years)
Examination
Passed
Name of the
Board/University
Year of
passing
Percentage
of Marks
obtained
Grade/ Division/
Class obtained


A copy of the related Marks Sheet duly certified by the office of posting and signed by the
member on reverse side of the same.
Office Code :


Office of
Posting

Controlling
D.O.

Controlling
R.O.

Employee No.

Membership No.

Date of joining
the Society
D D M M Y Y Y Y

Members Full Name :

Designation : Department :

_______________________
Date: Signature of the Member
YES NO