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 : BHAGIRATHI SANKHUA
2 Aadhaar number : 548738206567
3 Name as per Aadhaar : BHAGIRATHI SANKHUA
4 Aadhaar linked mobile number : 9556747047
5 Gender : Male
6 Marital status : Married
7 Father's name : NARAYAN SANKHUA
8 Spouse's name : ANNAPURNA SANKHUA
9 Date of birth : 25/07/1978
10 Permanent address
(a) Permanent address : BALASORE, SORO, TUNDAPADA
(b) State : ODISHA
(c) District : BALASORE
(d) ULB : Soro
(e) Ward : Soro (M) - Ward No.16
(f) Pincode : 756045
11 Present address
(a) Present address : BALASORE, SORO, TUNDAPADA
(b) District : BALASORE
(c) ULB : Soro
(d) Ward : Soro (M) - Ward No.16
(e) Pincode : 756045
12 Details of family members
# Name Aadhaar Number Date of birth Relation with the applicant
1 ANNAPURNA SANKHUA 666780768880 07-04-1982 Wife
2 KRUSHNA CHANDRA 839183865148 12-11-2003 Unmarried son
SANKHUA
3 PUSPALATA SANKHUA 690881424527 11-07-1948 Dependent mother
4 MONALISA SANKHUA 312342373578 24-07-2006 Unmarried daughter
13 Details of the establishment(s)
1 (a) Name of Establishment / Employer : RAJENDRA NAYAK
(b) Establishment Sector : Private
(c) Establishment Address : BALASORE, SORO, TUNDAPADA, KEDARPUR, 756045,
Soro, BALASORE, ODISHA, 756045
(d) Contact number : 9556747047
(e) Registration number :
(f) From : 03/01/2024
(g) To : 04/09/2024
(h) Employment certified by : Self certification
14 Nature of job : Painter
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 : 02161510814
19 Category : OBC
20 Religion : Hindu
21 Physically challenged : NO
22 Bank account details
(a) Aadhaar linked bank account number : 03710110146606
(b) Bank IFSC : UCBA0000371
(c) Name of bank : UCO BANK
(d) Branch of bank : SORO
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 : BALASORE Signature of the applicant
Date : 24/09/2024
(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 : KRUSHNA CHANDRA SANKHUA
Aadhaar of nominee : 839183865148
Address : BALASORE, SORO TUNDAPADA
Relationship : Unmarried son
Account Number : 3474936423
Bank name : STATE BANK OF INDIA
Branch name : SORO
IFSC : SBIN0007980
Date of birth : 12/11/2003
Percentage of share : 100.0
