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English Application Form

This document is an application form for migrant workers seeking employment within or outside of India. It requests personal details of the applicant such as name, contact information, address, photo ID numbers. It also requests employment details such as the nature of work, dates of migration, information about agents or employers. Finally, it requests bank details and attached documents like photos and identification cards to complete the application.

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jakirhossain12881
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106 views2 pages

English Application Form

This document is an application form for migrant workers seeking employment within or outside of India. It requests personal details of the applicant such as name, contact information, address, photo ID numbers. It also requests employment details such as the nature of work, dates of migration, information about agents or employers. Finally, it requests bank details and attached documents like photos and identification cards to complete the application.

Uploaded by

jakirhossain12881
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application Form

1. PERSONAL DETAILS
A. Name of the Applicant* : .....................................................................
B. Mobile No.* : .....................................................................
C. Father/Husband’s Name*: ...................................................................
D. Gender* : Male / Female / Others
E. Date of Birth* : .....................................................................
F. Emergency Contact No.* : .....................................................................
G. Aadhaar No.* : .....................................................................
2. PERMANENT ADDRESS* ---
Sub-Division* Block/ GP/Ward* Police Station* PIN Code*
Municipality/Corporation*

3. WORKSITE ADDRESS* --- Anyone of A/B/C/D


A. For applicant who is engaged within India (other than West Bengal)
Country State / UT* Worksite Police Station*
India

B. For applicant who is engaged outside India


Name of the Country : Worksite address : Valid Passport No.

C. For applicant who is likely to be engaged within India (other than West Bengal)
Country State / UT* Worksite Police Station*
INDIA
D. For applicant who is likely to be engaged outside India
Name of the Country : Worksite address : Valid Passport No.

4. NATURE OF EMPLOYMENT* : Agriculture/ Construction/ Garments/ Healthcare/ Hospitality/ Jewellery/


Manufacturing/ Stone Cutting & Polishing/ Transport/ Self Employed/ Miscellaneous :
..................................................
Migrated on/likely to be migrated on *(Date-ranging from last one year
to next one month)
5.* SELF ENGAGED / ENGAGED THROUGH AGENT / ENGAGED WITHOUT AGENT / ENGAGED THROUGH
OTHERS
A. Agent* / Other person’s Name: ...........................................................................................................................
B. Agent* / Other person’s Mobile No. : ..................................................................
C. Agent* / Other person’s Address: ........................................................................................................................
I. Employer’s Name: ........................................................ II.Employer’s Phone/Mobile No. : ...................................
III. Employer’s Address :
.....................................................................................................................................................................................
.....................................................................................................................................................................................
6. BANK Bank Name : Branch Name :
DETAILS(Bank to be
located in WEST
BENGAL)*
Account Number : IFS Code :

7. NOMINEE DETAILS* Nominee Name : Mobile No. :

Relationship with the Nominee : Aadhaar No. :

8. RATION / KHADYA SATHI CARD DETAILS OF THE APPLICANT*


Ration / Khadya Sathi Card Type (AAY/SPHH/PHH/RKSY-I/RKSY-II)
Ration / Khadya Sathi Card Number
9. Do You Have Family ( Yes / No )* : .................
Family Members' Name* Gender* Age Aadhaar Number* Relationship*
(Male/
Female/
Others )

Submit photocopy of following documents 1. Passport Size Photo 2. Aadhaar Card 3. Bank Passbook 4.Annexure-A
with Application* 5. Photocopy of valid passport (if required)
Fields marked with Star (*) are mandatory
The above declaration is true to my knowledge and belief.

Signature of the Migrant Worker


Place: Date

ANNEXURE-A
SELF DECLARATION
I,Shri/Smt./Miss: ………………………………………………………………………………………
Son/daughter/wife of ………………………………………AADHAR No……………………………
Permanent resident of ………………………………………………………………………………….
hereby declare that I have migrated/ will migrate as …………………….. (Profession) for work at
work place
WITHIN INDIA of District ………………………………….. of State….……………………………..
/OUTSIDE INDIA…….........................(Name of the Country) On ………………….
The above declaration is true to my knowledge and belief.
Signature of the migrant worker with date : …………………………………………………………

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