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 : Gautam Kuldeep
2 Aadhaar number : 860857809815
3 Name as per Aadhaar : Gautam Kuldeep
4 Aadhaar linked mobile number : 7894873448
5 Gender : Male
6 Marital status : Married
7 Father's name : Sonsai Kuldeep
8 Spouse's name : Semati Kuldeep
9 Date of birth : 10/07/1989
10 Permanent address
(a) Permanent address : AtDhamanpuri, p/oOTanwat, DistDistNuapada, Pin766105
(b) State : ODISHA
(c) District : NUAPADA
(d) Block : NUAPADA
(e) Village : Dhamanpuri
(f) Gram panchayat : TANWAT
(g) Pincode : 766105
11 Present address
(a) Present address : AtDhamanpuri, p/oOTanwat, DistDistNuapada, Pin766105
(b) District : NUAPADA
(c) Block : NUAPADA
(d) Village : Dhamanpuri
(e) Gram panchayat : TANWAT
(f) Pincode : 766105
12 Details of family members
# Name Aadhaar Number Date of birth Relation with the applicant
1 NAMAN KULDEEP 480406398563 14-07-2019 Unmarried son
2 Semati Kuldeep 662508126003 08-03-1996 Wife
13 Details of the establishment(s)
1 (a) Name of Establishment / Employer : Nuapada
(b) Establishment Sector : Private
(c) Establishment Address : Nuapada , NUAPADA, NUAPADA, ODISHA, 766105
(d) Contact number : 7894873448
(e) Registration number : NA
(f) From : 20/12/2023
(g) To : 15/12/2024
(h) Employment certified by : Self certification
14 Nature of job : Mason (Mistri)
15 Educational details : Graduation
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 : 25042812868
19 Category : SC
20 Religion : Hindu
21 Physically challenged : NO
22 Bank account details
(a) Aadhaar linked bank account number : 20095354608
(b) Bank IFSC : SBIN0006078
(c) Name of bank : STATE BANK OF INDIA
(d) Branch of bank : ADB NUAPADA
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 : NUAPADA Signature of the applicant
Date : 19/12/2024
(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 : Semati Kuldeep
Aadhaar of nominee : 662508126003
Address : AtDhamanpuri, p/oOTanwat, DistDistNuapada, Pin766105
Relationship : Wife
Account Number : 38457069450
Bank name :
Branch name : SBI NUAPADA
IFSC : SBIN0000142
Date of birth : 08/03/1996
Percentage of share : 5050.0
