12 Details of family members

# Name Aadhaar Number Date of birth Relation with the applicant

1 AMAR NAIK 779698235900 13-03-2002 Unmarried son

2 JYOTIRANI NAIK 477582946039 29-12-2005 Unmarried daughter

13 Details of the establishment(s)

1 (a) Name of Establishment / Employer : NANDA NAIK

(b) Establishment Sector : Private

(c) Establishment Address : BARSINGA, RANJAGOLA, BALIMI, DHENKANAL,

Barasingha, Barasingha, DHENKANAL, ODISHA, 759020

(d) Contact number :

(e) Registration number :

(f) From : 11/12/2022

(g) To : 08/12/2023

(h) Employment certified by : Self certification

14 Nature of job : Helper to Mason(Mistri)

15 Educational details : Matriculation

16 Training details :

17 (a) Are you a migrant worker : NO

18 (a) Do you have NFSA or SFSA? : Yes

(b) NFSA / SFSA card number : 09040110915

19 Category : SC

20 Religion : Hindu

21 Physically challenged : NO

22 Bank account details

(a) Aadhaar linked bank account number : 35704097221

(b) Bank IFSC : SBIN0004856

(c) Name of bank : STATE BANK OF INDIA

(d) Branch of bank : KHAJURIAKATA

 (FORM XXXI)

[See Rule 265(2) and 266 (4)]

NOMINATION FORM

I nominate the following person/persons as rightful dependants, to receive all the dues from the building and other
construction workers' welfare board on my behalf and in the event of my death as rightful heirs to receive all benefits
due to me.

1 Name : AMAR NAIK

Aadhaar of nominee : 779698235900

Address : BARSINGA, RANJAGOLA, BALIMI, DHENKANAL

Relationship : Unmarried son

Account Number : 34072179059

Bank name : STATE BANK OF INDIA

Branch name : KHAJURIAKATA

IFSC : SBIN0004856

Date of birth : 13/03/2002

Percentage of share : 100.0