FORM (A) Application for allotment of House 1. (a) First preference _______________ (b) Second Preference ______________ 2. APPLICANTS (a) Full Name (in block letters)_______________ (b) Present address________________ (c) Permanent address_____________ 3. Was the applicant’s present accommodation provided by his employer_____________ if so, why the applicant wants to shift from there? _________________ 4. Occupation of the applicant (with details and Ticket No., if any)__________________ if permanent, temporary, probationary or casual _____________________. 5. Initial pay, allowances and their total pay Rs. ___________________. Allowance : Rs. _________ Total : Rs._________ 6. Employer’s— (a) Full name and address _________________________ (b) Date of employment under the present employer___________________ I hereby agree that in case house is allotted to me, Government may get the payable rent and other dues deducted from my pay or wages, as the case may be, through my employer every month. I declare that the above statement is correct and if any of the above statements is found incorrect I may be asked to vacate the house immediately. _____________________ Signature of the applicant Dated_______________ Certified that the applicant is an industrial worker according to Section 2(1) of the Factories Act, 1948, and the statement given by him above/overleaf is correct. _____________________ (Signature of the Labour Welfare Officer) ___________________ Signature of employer --------------
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