FORM - X
APPLICATION OF SEPERATED EMPLOYEE FOR PAYMENT OF
1997 WAGE REVISION ARREARS, PF & GRATUITY ARREARS.
1.
Name of the Ex-Employee
(Full name in Capital letters)
:
2.
Badge No.
:
3.
Date of joining in BHPV
:
4.
Date of Separation
:
5.
Designation & Dept. at the
time of separation
:
6.
Reason for separation
:
7.
Present Postal Address
with Pin Code.
:
8.
Telephone No. (Land line)
:
9.
Mobile No.
:
10. Email ID
PHOTO
OF
CLAIMANT
VR / Retired / Resigned / Terminated
:
11. Please indicate whether photo copies :
of the following documents are
enclosed or not.
a) Relieving order/ Service
Certificate / ID card
:
Yes / No
b) Aadhar Card / Driving
License / Ration Card /
Latest landline telephone bill
:
Yes / No
c) PAN Card
:
Yes / No
d) First page of Bank Pass Book
:
Yes / No
e) Cancelled Cheque leaf
:
Yes / No
f) Pension Order
:
Yes / No
Signature of the claimant
;; 2 ::
DETAILS OF BANK ACCOUNT
01.
NAME OF THE BANK
02.
NAME OF THE BRANCH
03.
BRANCH CODE
04.
ACCOUNT NUMBER
05.
IFSC CODE OF THE BRANCH.
Declaration
I, ……………………………………………S/o, W/o ……………………………..,aged------Years, residing at H.No. ………………………, Village ……………………………………..
Taluk / Mandal ……………………..… District ………………………….. State …………….
do hereby declare that all the details furnished by me in the format are true to the best of my
knowledge/ belief. I will be responsible for any wrong information given OR any relevant
information suppressed and I will be liable for any civil / criminal action initiated by BHEL,
HPVP, Visakhapatnam.
Place :
Signature :
Date :
Name
:
FORM - D
APPLICATION BY DEPENDENTS OF DECEASED EMPLOYEE FOR PAYMENT
OF 1997 WAGE REVISION ARREARS, PF & GRATUITY ARREARS.
1.
Name of the Ex-Employee
(Full name in Capital letters)
:
2.
Badge No.
:
3.
Date of Separation
from employment
:
4.
Date of death
:
5.
Name of the claimant
:
6.
Relationship with the deceased
employee
:
7.
Present address of the claimant
with Pin Code.
:
8.
Telephone Number (Land line)
:
9.
Email ID
:
PHOTO
OF
CLAIMANT
10. Please indicate photo copies
of the following documents are
enclosed or not.
a) Service Certificate /
Relieving Order / ID Card
of the employee
:
Yes / No
b) Pension order of the employee
and the spouse
:
Yes / No
c) Death certificate of the
employee
:
Yes / No
d) Legal heir / proper person
Certificate issued by MRO/
Tahsildar / succession
certificate issued by Court.
:
Yes / No
e) Aadhar card / Driving Licence/
Ration Card /Latest Land line
phone bill of the claimant
:
Yes / No
Signature of the claimant
: 2 :
f) PAN Card of the Claimant
:
Yes / No
g) First page of Bank Pass Book
:
Yes / No
g) Cancelled Cheque leaf
:
Yes / No
DETAILS OF BANK ACCOUNT
01.
NAME OF THE BANK
02.
NAME OF THE BRANCH
03.
BRANCH CODE
04.
ACCOUNT NUMBER
05.
IFSC CODE OF THE BRANCH.
Declaration
I, ……………………………………………S/o, W/o ……………………………..,aged------Years, residing at H.No. ………………………, Village ……………………………………..
Taluk / Mandal ……………………..… District ………………………….. State …………….
do hereby declare that all the details furnished by me in the format are true to the best of my
knowledge/ belief. I will be responsible for any wrong information given OR any relevant
information suppressed and I will be liable for any civil / criminal action initiated by BHEL,
HPVP, Visakhapatnam.
Place :
Signature :
Date :
Name
: