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

LABOUR- MATERNITY BENEFIT FORM A

                                                           FORM A
                                                        (See rule 3)
                                                      MUSTER-ROLL

1. Name of Establishment:

2. Name of woman and her father's
    (or, if married, husband's) name.

3. Date of appointment.

4. Nature of work.

5. Dates with month and year in which she is employed, laid off and not employed.

No. of days                  No. of days      No. of days not        Remark
employed                      laid off                  employed






6. Date on which the woman gives notice under section 6.
7. Date of discharge/dismissal, if any.
8. Date of production of proof of pregnancy under section 6.
9. Date of birth of child.
10. Date of production of proof of delivery/miscarriage/
     1[Medical Termination of pregnancy/ tubectomy operation/death.]
11. Date of production of proof of illness referred to in section 10.
12. Date with the amount of maternity benefit paid in advance
      of expected delivery.
13. Date with the amount of subsequent payment of maternity benefit.
14. Date with the amount of bonus, if paid, under section 8.
15. Date with the amount of wages paid on account of leave
       under section 9.2[15A. Date with the amount of wages paid on account
       of leave under section 9A.]
16. Date with the amount of wages paid on account of leave
     under section 10 and period of leave granted.
17. Name of the person nominated by the woman under section 6.
18. If the woman dies, the date of her death, the name of the person
      to whom maternity benefit and/or other amount was paid,
      the amount thereof, and the date of payment.
19. If the woman dies and the child survives, the name
     of the person to whom the amount of maternity benefit
      was paid on behalf of the child and the period for which  it was paid.
20. Signature of the employer of 3[the mine or circus]
      authenticating the entries in the muster-roll.
21. Remarks column for the use of the Inspector.