Form II

[See Rule 20]

Common Application Form for claiming benefits of Group Insurance Scheme/ Educational Assistance/

Medical Assistance from the Arunachal Pradesh Building & Other Construction Workers’ Welfare Board

under provisions of the Code on Social Security Arunachal Pradesh Rules, 2021.

1. Name of Applicant

2. Father’s/Mother’s/Husband’s name

3. Residential Address

4. Date of Birth

5. Registration Number (attach proof)

6. Aadhar Number

Bank Account No & IFSC Code ( attach

7.

copy of Bank Passbook – front page only)

8. Contact number (mobile or landline)

9. Application for Benefit (name of the Scheme)

DECLARATION BY THE APPLICANT :

I hereby declare that the furnished particulars and facts are correct and true to the best of my

knowledge and belief. Further, I declare that any similar assistance have not been availed from any

other Board or body constituted by the government. In the event of any information given above

being found to be false, I shall refund the amount received as assistance and be liable for legal

action.

This declaration is made in sound mind and good health.

Date : Name and Signature of Applicant

Place :

Enclosures :

1.

2.

3.

4.

5.

Sl.

Scheme of Benefits Documents and Particulars Required

No.

(i) Name of student

(ii) Name of Institution & the Name and Year of Course

1. Educational Assistance (iii) Bank Account details of student

(iv) Certificate of Bonafide Student from the Institution

(v) Receipt of Course fees including hostel fees, in original.

(i) Medical Certificate, in original, from Authorised Medical

Practitioner

2. Medical Assistance

(ii) Original Bills and Cash Memo along with copy of prescription

3. Group Insurance As may be specified by the government

Scheme

4. Any Other Scheme As may be specified, from time to time

(Space below for office use only)

SCRUTINY AND VERIFICATION OF APPLICATION :

After a thorough scrutiny of the application with respect to the records available with this office the

following observations are made below :-

1. The applicant is a registered member of the Board under Registration No. . . . . . . . . . . . . . dated . . . . . . . . .

2. The applicant has/ haven’t availed similar assistance on earlier occasion for an amount of . . . . . . . . . . . .

vide office Order No. . . . . . . . . . . . . . . . . . . . . . . . .dated . . . . . . . . . . . . . . . . .

3. (Any other observations, if any) :

Date : Signature and Name :

Beneficiary Registering Officer :

Place :

RECOMMENDATION/ REJECTION OF APPLICATION :

Upon the scrutiny and verification of the application and the observations made by the

Beneficiary Registering Officer, the application of the applicant . . . . . . . . . . . . . . is hereby

recommended/ rejected for the grant of (name of benefit/scheme) . . . . . . . . . . . . . . . . . . . . . . .

Reasons for Rejection (in brief), if any :

Signature and Name :

Designation with seal:

District Labour Officer/ In-charge District Labour Officer