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 : JHUNU BEHERA
2 Aadhaar number : 220260679986
3 Name as per Aadhaar :
4 Aadhaar linked mobile number : 8984541423
5 Gender : Female
6 Marital status : Married
7 Father's name : UJALA BEHERA
8 Spouse's name :
9 Date of birth : 17/07/1980
10 Permanent address
(a) Permanent address : KHALINGI
(b) State : ODISHA
(c) District : GANJAM
(d) Block : SANAKHEMUNDI
(e) Village :
(f) Gram panchayat : KHALINGI
(g) Pincode :
11 Present address
(a) Present address : KHALINGI
(b) District : GANJAM
(c) Block : SANAKHEMUNDI
(d) Village : Khallingi
(e) Gram panchayat : KHALINGI
(f) Pincode :
12 Details of family members
# Name Aadhaar Number Date of birth Relation with the applicant
1 NARASINHA BEHERA Husband
2 MADAN BEHERA Unmarried son
3 SUNILA BEHERA Unmarried son
4 LIJA BEHERA Unmarried daughter
5 ANILA BEHERA Unmarried son
13 Details of the establishment(s)
14 Nature of job : Unskilled Construction Worker
15 Educational details :
16 Training details :
17 (a) Are you a migrant worker : NO
18 (a) Do you have NFSA or SFSA? :
19 Category : OBC
20 Religion :
21 Physically challenged :
22 Bank account details
(a) Aadhaar linked bank account number : 33761305876
(b) Bank IFSC : SBIN0006473
(c) Name of bank :
(d) Branch of bank : KONKARADA
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 : GANJAM Signature of the applicant
Date : 15/11/2017
(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 : NARASINHA BEHERA
Aadhaar of nominee :
Address : AT/PO-KHALINGI PS-PATAPUR GANJAM
Relationship : Husband
Account Number :
Bank name :
Branch name :
IFSC :
Date of birth :
Percentage of share : 100.0
