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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