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Documents to be Submitted withApplication: •

1. sSx^^cb s^^^si^^et^F o^^oi t^3SJ23^"

(wodS)^ sisii^^c^oi ^e^ ort^*5^)Ci)

Three Passport Size Photos (one

affixed on the Form)

W5jO4tJ 3o^d>, SBffli ** 333^ ^03^

Bank Name, Branch and AccountNumber: . •

oiffls^o'/tSffldnMS ^oais

Mobile /Phone Number:

BO23 ^TO^i/

Postal Address:

Driving License No:

>&& ^3eu ^o^y (ati, )BPL Card Number (Optional) :

'a^a^ (siaioscid **^si ^eU)/

EPIC (Voter ID):

Adhaar Card Number:

233^ /Caste:

Educational Qualification:

^ot3/rtotS5^ ^^*/Father's7 Husband's Name :

wsJ 0530^/ Date of Birth:

^^5*/ Name:

Application for Selection as Voluntary Karmika Bandhu for KBOCWWB and

KSUWSSB under Ambedkar Karmika Sahaya-Hastha

jfc^^oi ^^^ oiotKcSoiS ^^raru^ ^ri si^ <a*3 ad^^rre

si* iterant^ craij B^o^'U^ ^^i^r^si ^rad^^^* ^^33 sio^^oi ^u^i

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sbedacbd ab^s^de^0^*to, 3do^3oi)3/sirtd

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Mtp^cici sS^d

DECLARATION

2.estp3ot ^^ts^Fd d,3/ Copy of Adhaar

Card3. aaae^/aaao* ^^^^F^S s^3

(esjpbs53rbdod) Copy of APL / BPL

Card (as applicable)

Copy of SSLC certificate

Copy of Caste Certificate (asapplicable)

6.^)0^? d^dji ^3/Copy ofDriving License

7.K33sob' SJBT^^^s^d ^,3/Copy of Bank

Pass Book

^3*3)30 d^^dOod ddd d^3t3Sl^/Certificate of Character from

concerned MP / MLA / DistrictMinister

Driving License Number. Mobile Numberfor Voluntary Karmika Bandhu under Ambedkar Karmika Sahaya Hastha in the

Gram Panchayat / Urban Local Bodyof TaiukaDistrict - has

been received.

Seal & Signature of Labour Officer

Acknowledgement

The Application Nodatedsubmitted by Sri/Smt/Kumari

AddressAdhaarNumber

3o.4_

data/ Acknowledgement

Declaration

The facts mentioned above are true to my knowledge and information. I wish to apply for selection as

Voluntary Karmika Bandhu on Commission Basis in the Grama Panchayat / Wards of

, Taiuka, District to assist the

KBOCWWB and KSUWSSB in registering unorganized workers, delivering claims and scheme benefits,

collecting contributions and depositing them to the Boards and creating awareness among unorganized

workers. I shall abide by the rules and conditions made by the Boards from time to time and shall work

diligently towards the uplift of unorganized workers. I confirm I am resident of the Grama Panchayat /

Urban Local Body mentioned above and I have no police record. I agree that this is a voluntary work on

commission basis and I am not entitled to any salary. I also agree that my selection does not amount to

any claims of any kind of employment now or in the future. I confirm that I shall myself carry out the

voluntary work and shall not sub-contract anyone else on my behalf. I understand that if any of the above

is found untrue or violated in the future my services will be terminated forthwith.

Place:

Date:Signature /Thumb impression of the Applicant.

Number Driving License Number

Mobile Number for Voluntary Karmika Bandhu under Ambedkar

Karmika Sahaya Hastha in the Gram Panchayat / Urban Local Bodyof Taluka

Districtis examined and he / she is selected / not selected for voluntary work on commission

basis for KBOCWWB and KSUWSSB as per approved norms..

The Applicant should report to training onatLocation to Labour Officer /

Inspector. the Applicant should collect his / her Smart Card on after

completionof training.-

Place:. •• .-....;• •••

Date:. .

Seal & Signature of Labour Officer

The Application ^No dated submitted by Sri/Smt/Kumari

AddressAdhaar

Voluntary Karmika Bandhu Selection / Rejection / Cancellation Order

Order No:

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