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/

m dd m L m

d A dh m / /

f h ㌳ A䇅 䇅 䇅 C 䇅 y t /
SC ST NT OBC GEN

UA If v 䇅 E IC m If v 䇅 Em If v 䇅
/ 䇅 䇅

Residential Address / ta㔀 t

R d c Typ / H Typ / H d 䇅 / /
d / R ch / cc

R d A C y

Imp c y
h h

c T k t/ ff c C d /

T C d / L d

Ch ck f m Add m R d Add / //

R d c Typ / H Typ / H d 䇅 / /

d / R ch / cc
R d A C y

L dm k c T k t/

ff c C d / T C d / L d

R C d m / / R C d Typ / /
m y / t /
1. 2. 3. 4.
First Name
 걐ს t
Surname
t
Father Name
香 걐 /ს 㔀 ს t
DOB
O t
Age(years)
( )
Relation
a
Aadhar No.
t
Profession
at
Education

Nominee

BOCW Reg No.
(if registrered)
BOCW ㌳䁓 㔀
( ㌳䁓 㔀 a ta)

k /
I CC d / k m /

k ch / k Add /

ICR C d / Acc m /

Emp y

m fC c v p C c C mp y m Typ fW k W kp c
/ / / / / / / /

h m t c T k t/ T C y

c d / App m t p ch W 䇅 p d y t

fW k : /
Details of the Days Wor ing Certi cate / 䁓 a 橔t t t t橔t 䁓t t t 㔀걐

Typ fI / /

R 䇅 dW h R 䇅 fI p ch m p ch
/ / / / / /

m fC c v p c f Emp y T k f Emp y
/ / / t/

1. 2. 3. 4.
Type of
Employer
t t t
Full Name
t
Mobile No.
㔀 .
Reg No. Of
Issuer / t
㌳䁓 㔀 .
From Date
t t ს ta
To Date
t ს 

pp 䇅d c m
DOCUMENT ATTACHMENT TYPE

1 h I f t A dh c d /
p
v 䇅Lc c /
C d /
E c C d
2 R d f t A dh c d /
p
v 䇅Lc c /
R C d /
L m h L 䇅h t /
mp ch y C Rc
3 f f A䇅 t A dh c d /
p
A C d /
v 䇅Lc c /
hC Rc ㌳
ch L v 䇅C Rc
4 h c py f k k / t/ 䘀 k k / t/

5 C fc f k 䇅 90 d y m h p v y C c v p / / /
/ ꘀ / / / m v kC Rc /
hm cp y m cp c p
/ /䁀 ꘀ /
h

Ih yd c h h f m d c m p vd d v f m &c c h f my k d䇅 d f
d h 䇅 h f y d I c y f h v f m f d f m d 䇅
m p 䇅, I m h Im y h d f
䁀 / / /, t
, / ꘀ / t t

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