KERALA SHOPS AND COMMERCIAL ESTABLISHMENT WORKERS
WELFARE FUND SCHEME, 2007
Form 1
Application for Registration and Nomination
[See Section 26(1)]
1. Name
Photo
2. Father's/ Husband's Name
3. Residential Address with Phone No:
a. Ration Card No. :
b. Voter ID Card No. :
4. Age & Date of Birth :
5. Marital status : Married/Unmarried/Widow
6. Employee/Self employee :
7. If employee, Nature of employment/:
Designation
8. Name and address of the Institution
with Telephone No.
:
9. Period of service in the present
Institution
10. Registration No. of the institution
as per Kerala Shops&Commercial
Establishments Act 1960
:
11. Details of family members of
applicant
:
:
Sl.No. Name of family Relationship Age Occupation Remarks
member with applicant
(1) (2) (3) (4) (5) (6)
12. Whether applicant is a member of
any other Welfare Scheme
:
13. If yes
(a) Name of Welfare Fund
(b) Date of admission
(c) Details of Payment
14. I certify that the above particulars are correct.
Signature of Applicant
Signature of Employer
with address and seal
Signature of the nspector District Executive Officer
Nomination
15. I hereby nominate the persons mentioned below to receive the amount of
financial assistance in the event of my death.
Sl.No.
Name of address Age Relationship with the Percentage of
of Nominee (s) applicant financial assistance to
be given to each
member
Signature of Applicant
For official use
Application accepted/rejected
Register No. if accepted
Reason for rejection
Place:
Date :
Inspector/ District Executive Officer
WELFARE FUND SCHEME, 2007
Form 1
Application for Registration and Nomination
[See Section 26(1)]
1. Name
Photo
2. Father's/ Husband's Name
3. Residential Address with Phone No:
a. Ration Card No. :
b. Voter ID Card No. :
4. Age & Date of Birth :
5. Marital status : Married/Unmarried/Widow
6. Employee/Self employee :
7. If employee, Nature of employment/:
Designation
8. Name and address of the Institution
with Telephone No.
:
9. Period of service in the present
Institution
10. Registration No. of the institution
as per Kerala Shops&Commercial
Establishments Act 1960
:
11. Details of family members of
applicant
:
:
Sl.No. Name of family Relationship Age Occupation Remarks
member with applicant
(1) (2) (3) (4) (5) (6)
12. Whether applicant is a member of
any other Welfare Scheme
:
13. If yes
(a) Name of Welfare Fund
(b) Date of admission
(c) Details of Payment
14. I certify that the above particulars are correct.
Signature of Applicant
Signature of Employer
with address and seal
Signature of the nspector District Executive Officer
Nomination
15. I hereby nominate the persons mentioned below to receive the amount of
financial assistance in the event of my death.
Sl.No.
Name of address Age Relationship with the Percentage of
of Nominee (s) applicant financial assistance to
be given to each
member
Signature of Applicant
For official use
Application accepted/rejected
Register No. if accepted
Reason for rejection
Place:
Date :
Inspector/ District Executive Officer