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