ODISHA BUILDING AND OTHER CONSTRUCTION WORKERS' WELFARE BOARD,
BHUBANESWAR.
(FORM XXVII)
[See Rule 265(1)]
APPLICATION FOR REGISTRATION OF BUILDING AND OTHER CONSTRUCTION
WORKERS'
1 Name of the construction worker : SAMINA KHATUN
2 Aadhaar number : 305425794583
3 Name as per Aadhaar : SAMINA KHATUN
4 Aadhaar linked mobile number : 8908960070
5 Gender : Female
6 Marital status : Married
7 Father's name : MD GULAM RASOOL
8 Spouse's name : MD IMAMUDDIN
9 Date of birth : 14/10/1967
10 Permanent address
(a) Permanent address : JAGANNATH COLONY
(b) State : ODISHA
(c) District : SUNDARGARH
(d) ULB : Raurkela
(e) Ward : Raurkela (M Corp.) - Ward No.2
(f) Pincode : 769004
11 Present address
(a) Present address : JAGANNATH COLONY
(b) District : SUNDARGARH
(c) ULB : Raurkela
(d) Ward : Raurkela (M Corp.) - Ward No.2
(e) Pincode : 769004
12 Details of family members
# Name Aadhaar Number Date of birth Relation with the applicant
1 MD IMAMUDDIN 556015869832 01-01-1967 Husband
2 FARHIN NISHA 423314929596 06-01-1999 Unmarried daughter
13 Details of the establishment(s)
1 (a) Name of Establishment / Employer : SUNDARGARH NIRMAN SHRAMIK SHAKTI
(b) Establishment Sector : Private
(c) Establishment Address : RAJGANGPUR, Panposh (CT), Panposh (CT),
SUNDARGARH, ODISHA, 769004
(d) Contact number : 9776492801
(e) Registration number : 237/RKL
(f) From : 18/12/2021
(g) To : 18/12/2022
(h) Employment certified by : Trade union
(i) Trade union name : SUNDARGARH NIRMAN SHRAMIK SHAKTI
(j) Certifying Person :
14 Nature of job : Helper to Mason(Mistri)
15 Educational details : Below 7th class
16 Training details : WORKER
17 (a) Are you a migrant worker : NO
18 (a) Do you have NFSA or SFSA? : NO
(b) NFSA / SFSS card number :
19 Category : General
20 Religion : Muslim
21 Physically challenged : NO
22 Bank account details
(a) Aadhaar linked bank account number : 10157350350
(b) Bank IFSC : SBIN0004859
(c) Name of bank : STATE BANK OF INDIA
(d) Branch of bank : PANPOSH
Declaration by the applicant
I am aware that if a person enter Aadhaar number of any other person and attempt to impersonate another person,
dead or alive, real or imaginary, he/she shall be punishable with imprisonment for a term which may extend up to
three years and shall also be liable to a fine which may extend to ten thousand rupees as per provisions of Aadhaar
act.
I hereby state that I have no objection in authenticating myself with Aadhaar based authentication system and giving
my consent to provide my Aadhaar number for Aadhaar based authentication for the purpose of establishing my
identity and delivery of services / assistances by OB&OCWW Board.
I hereby declare that my application will be rejected if it is found that I have provided wrong Aadhaar number or
Aadhaar number of someone else's.
I hereby declare that for any wrong entry in bank account details by me, the OB&OCWW Board will not be responsible
for mis-credit and I will be held responsible for the same.
I hereby declare that the particulars given above are true to the best of my knowledge and belief.
Place : SUNDARGARH Signature of the applicant
Date : 18/12/2022
(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 : FARHIN NISHA
Aadhaar of nominee : 423314929596
Address : JAGANNATH COLONY
Relationship : Unmarried daughter
Account Number : 33131666262
Bank name : STATE BANK OF INDIA
Branch name : PANPOSH
IFSC : SBIN0004859
Date of birth : 06/01/1999
Percentage of share : 100.0
