Form-xLit (ai @"- XLII) (See Rule 275) [Gan - 998] APPLICATION FOR FINANCIAL ASSISTANCE FOR THE EDUCATION OF CHILDREN OF THE BENEFICIARY FOIA AAINIOR AA ASIANS! Fes Alleqae ag To The Secretary, Odisha Building & Other Construction Workers’ Welfare Board /District Labour Officer. gisaa, 259, 6Sall S@IOIOIS G aioHiaY Sela aie aqui 6ais | OQ! A AUHIer 1. (a) Name of the registered Construction Workers (@) DBQES Sri Aes oF (b) Sex (st) oie (c) Marital Status (a) 6Gaw@e GS (d) Father's Name / Husband's name (a) Gel / sen oI (e) Date of birth/age (@) 9g eG | e2a (f) Present Address (9) eSr1OR Sere! (g) Permanent Address (8) gal Geel 2. Name, Address, Registration No. of the Establishment where the Worker is working. _ AGaPAIA Gia aldiagaal GSaiea OIA, O@Ell 6 CQHSGAM PAR 3. Nature of job alae ola Enclose th pass port size colour photo asad age ese ong (608)a . BPL/Antyodaya Mention Card No. 6.ANQ/ 26eI0q aS EAA (QSan) 5. (I) Whether SC/ ST/SEBC (@) AQQSE @IG/ @ORIG/ Age act (11) Whether Minority/ Physically Challenged/ etc. (G1) PeHiAgd / Hew Asa aod 6. (a) Registration No. of the beneficiary (@) BEIGE ABER PRR (b) Date of Registration (@) ABaaE Biss 7. Bank Account No. Name of Branch/Bank HIF AGE PRR | QUE SIA OIE 8, Details of son (s) /daughter(s) for whom: Education assistance is sought PAIGE Cacia AGQe SelumMs ga b eas Sge Sone Sl.No. [Name | Date of | Examination] Name of | Name of | Admitted ee. oe birth passed the the in Class / @q.916% | GacTaatea | School | Educational | Year 8g seiaas =| amaein | institution | der where secisaa reading —_| a@aska oF eqge! 621086 daigaea in (Attested Xerox copy of the mark-sheet shall be enclosed) (AEA ( ASSES GE) PAR ATE AHIAIOrR QIAEA EAA GAG) Place (q@): Date (@I&s1): Signature/Thumb impression of the Registered Beneficiary AAS SolURIOIR OgsIe / CASQ