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CHAPTER 1 - Border Roads Organisation

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RESTRICTED<br />

Appendix “A”<br />

APPLICATION FORM FOR MEMBERSHIP OF THE BENEVOLENT FUND<br />

1. Name (in full)<br />

Designation<br />

Shri/Smt.Kum___________________________________<br />

2. Father‟s/Husband‟sName<br />

3. Date of birth/retirement<br />

4. Whether permanent or<br />

Temporary<br />

5. Name of the<br />

section/office, where<br />

working<br />

I hereby declare that I have read the Model Rules of the Benevolent Fund and am<br />

desirous of becoming a member of this Fund. I agree to pay Rs ____________ (Rupees<br />

_____________________________________ only) annually towards the subscription of this<br />

fund.<br />

Signature ____________________________<br />

Dated_______________________________<br />

Verification certificate from Administration Wing of the Department/office.<br />

Certified that Shri/Smt/Kum. __________________________ son/wife/daughter of<br />

____________________________________________________ is a regular/permanent servant<br />

in the grade of ________________________________ in this Ministry/Department/Office.<br />

Signature of the OC Unit/TF/CE<br />

188<br />

RESTRICTED

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