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ASSAM BUILDING & OTHER CONSTRUCTION WORKERS’ WELFARE BOARD
Guwahati-16
SP IR ST SeyHD Fretie afte Same oifere
watail-se
FORM No. XXVI
BAT-R&
APPLICATION FOR REGISTRATION
AGI GICATA
Applicatic
Date ..
4 copies of passport
size photo
ta a 8 I
1) Name of applicant :[
BICTHTSTT ATS
2) Father’s/Husband’s Name
‘Pret paris ara
3) Address in full
ae Beat
(a) Permanent address
“ae Beat (B) Present address :
edu Deal
4) Whether General /SC/ST/OBC/Others +
«
‘ertificate should be submitted)
metas erifea/ eepohe enfe fermehe (sare
Fraetat erfe/ aires (ara ta wife ofa
auPia)
3) Male/
eu / aide
6) Marital status
(Married/ Unmarried)
‘taaikee Fyfe
(Rake sara)
7) Name of wife/husband
ont Partie am
8) Date of birth
wre wriee
9) Date of retirement
wa CH
10) Name & address of the employer/
establishment where the
applicant is working
Ee
]
r
Day fi = Month ste _Vear ava
Lae). Garey Ooo
Day fii = Month we Year axa
| a OO Oooo
oremereaia Remit ef / afore
arm ate Brat
11) Nature of job
exlg erg Pr 12) ESUP-F No(if any)
exter Stat / fears Fare aR Cal TER)
13) Total years of service up to
Registration
AGHA YD Cra aT
14) Rate of subscription :
aa faa free
Rs. 20/+ per month
30,00 Bet af
15) Name of the Bank & Branch where
subscription is to be paid
CARA ATR Ge TAT AS Aw STATE A
16) Particulars of nominee
Tatts artes eae
17) If the applicant is already a member of :
any other Welfare Board, the name of
such Board & Registration No. of the
‘Applicant
safe encarrsreTal BAT TCA ATT FTN
Sy BE, CAR fae AT ATE META HOT
18) Whether wife/husband a member of +
this board? (Yes/No)
aA Pat ok afrra 7S APE?
(aa / AeA)
: Nomination Form No, XXVII attached herewith
Tented at fa ae 298 UT ATS AICTE wal et 19) If'so, name & registration No. & Date +
aft ea coca ara wie seta ae ate wie
The above facts are true to the best of my knowledge & information.
‘SHANE CAPR GIA SI BIS BHOEPIA AES |
Signature / Thumb impression of the Applicant
SITTERS BET / at rg Bt
