Download 1. Application form for registration of unorganized workers

ANNEXURE TO NOTIOFICATION No.5/215/2009–Lab dated 10-6-2016
FORM FOR APPLICATION FOR REGISTRATION OF UNORGANISED WORKERS.
(See Rule 12)
To
The Deputy Commissioner,
…………………………………………District, Manipur.
or such officer as specified by the State Government of Manipur.
Sir,
I beg to apply for registration of myself as an unorganized
worker under Rule 10 of the Manipur Unorganized Workers’ Social Security
Rules, 2016. My particulars are given below :1.
2.
3.
4.
5.
Name and surname.
Father’s/husband’s name.
Date of birth.
Occupation.
Whether belongs to BPL family
or not.
6. AddressPresent Address.
…..…………………………………………………….
...…..…………………………………………………
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
-
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
Village/Town
Taluka
Tahsil
Police Station
Post Office.
District
Permanent Address.
-
Village/Town
Taluka
Tahsil
Police Station
Post Office.
District
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
…..…………………………………………………….
…………………………………………………….
…………………………………………………….
2………contd
2
7.
Details of dependents (father, mother, children and others).
Sl. No.
1
2
3
4
5
6
7
8
Name
Age
8.
Bank name and Account No.
9.
Aadhar Card No.
Occupation
…………………………………………………………
…………………………………………………………
…………………………………………………………
DECLARATION
I declare that all information provided above is correct and that I am
a home-based worker/self-employed worker/wages worker in the
unorganized sector/a worker in the organized sector not covered by any of
the following Acts, namely –
-The Employees’ Compensation Act, 1923.
-The Industrial Disputes Act,1947.
-The Employees’ State Insurance Act,1948.
-The Employees’ Provident Fund and Misc. provision Act, 1952.
-Maternity Benefit Act,1961 and
-The Payment of Gratuity Act,1972.
Therefore, I may be registered as unorganized worker as defined by
section 2(m) of the Unorganized Workers’ Social Security Act, 2008.
Date…………………….
Signature of Applicant
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