- (See clause 7 of SSY read with clause 7(1) (2) of SSY (R&R), 2017) Form -1 ‘he Tole oT Pat and Not Fos ave be find meant corals apleaton wieder he olan fable fo be canoe (See clause 7 of SSY read with clause 7(1) (ay of SSY (R&R), 2017) Application No. i Application Form for Registration under Samajik Suraksha Yojana (SSY) (For Unorganised Sector Workers, Construction Workers & Transport Workers) (tre ect jhoto To . The Registering Authority hereby apply to enrol myself as a beneficiary under SAMAJIK SURAKSHA YOJANA and the following statements in elation to this application are given by me. 1 am already enrojled under WBB&OCWW Scheme / WBTWSSS) estwhile SASPFUW (strike out whichever snot applicable) and the R,gistation No. is PART-1 My Name is Sri / Smt. Father's / Husband’s Name ¢ - Mobile No. BPL : Y/N Ifyes, BPL No. . Bank A/C. No... 5. Bank & Branch Name. Permanent Address = Present Address 8a) Name of the Block / Municipali .) GP / Ward of the Municipality. 9. Ses Male / Female / Others 10. Marital status : Married / Unmarried / Widow / Divorce 11, Caste: SC/ST / OBC / Gen 12 Religion 13, Date of Birth : (DD/MM/YYYY) 14 Ages 15. Tam covered / not covered under the Employees’ Provident Ind and Miscellaneous Provisions Act, 1952 & ESI Act, 1948 (if yes, then provide P.F/ESI No. 16. Lama self-employed worker / worker engaged in the scheiuled unorganised sector under the Scheme, (Strike out which is 1 applicable) (i) Name of my Occupation / Self-employment coun: (strike out which is not applicable) (ii) Address of the Establishment where I employed. (Gitrike out if not applicable) 17, My monthly family income from all sources : Rs. 18. agree to abide by the Samak Suraksha Yojana (Rules & Regulations), 2017. i gissare it fhe Applica) RECEIPT Application No. New Registration / Existing Registration No. of the Applicant Received an application from Sri / Smt Address, for enrolment 5 neficiary under Samajik Suraksha Yojana.PART- DETAILS OF FAMILY MEMBERS FULLY DEPENDENT ON THE APPLICANT = Relationship ‘Whether Reyistered under a Name withthe” | Sex | Age | SASPFUWIBOCW/WBTWSSS, | Aadhar No. if any applicant i Yes, then Regn. No. Place Date (Pui Signatire 7 UTI of he Appiicani) PART-II NOMINATION FOR THE SCHEME a Relationship Bank AICNo, i eat ‘with the sex | Age | share | Name & Branch spplicant [Name ofthe Bank Place ieee Date (Fu Signature / UTI of the Applicant) PART-IV. CERTIFICATE, (To be given by : Employer / MP/ MLA / Sabhadhipati of Zilla Parishad / Sabhadhipati of Siliguri Mahakuma Parishad / Mayor of Municipal Corporation / Chairman of Borough Committee / Sabhapati or Member of Panchayat Samity, Pradhan of Gram Panchayat, Chairman / Vice-Chairman / Couneillor / Commissioner of Municipality or Corporation ‘Area, Eleoted Members of GTA) I know the applicant Sri / Smt and hereby certify that above statements made by him / her are true to the best of my knowledge and belief. Signature Full Name (Seal ) PART-V. (For Construction Workers and Transport Workers Only) (@) Ifa Construction Worker : Y/N {Lam also willing to avail the existing benefits under WBB&OCWW scheme for which Iam submitting separate application under e-district (www.cdistrict.wb. gov.in/PACE) () Ifa Transport Worker : Y/N Lam also willing o avail the existing benefits under WBTWSS scheme for which am submitting separate application under e-district (www.edistrict wb. gov.in/PACE)