ANNEXURE-I

APPLICATION FOR UNEMPLOYMENT ASSISTANCE UNDER THE YUVA UTSAHA

PRAKALPA-2013 SCHEME
1. Name of the Applicant (in Capital letters):
2. Enrolment Number in Employment Bank:
3. hether !nemploye" till "ate : #E$%N&
(Certificate from a 'roup (A &fficer to be attache")
). Name of the *ea" of +amily (in Capital letters):
,. -ostal A""ress .ith -/N :
0. 1ate of Birth:
2. 3ation Car"%4oter5s /"entity Car" Number:
(Atteste" photocopy to be submitte")
6. Bank Account 1etails (7o be opene" in any nationali8e" banks9 preferably $.B./)
i) Name of the Bank branch:
ii) Account Number :
iii) /+$C co"e :
i:) ;/C3 co"e :
<. hether recei:e" financial assistance in any 'o:ernment sponsore" $elf=Employment scheme in the
past : #E$%N&.
11. hether any other member of his%her family has applie" for !nemployment Assistance un"er this
scheme : #E$%N&
12. Declaration: 7he information pro:i"e" by the un"ersi>ne" here abo:e are true an" / shall be liable
for the penal action that may be taken up by the 'o:ernment in case any of these information is pro:e" to
be false subse?uently. / shall forth.ith inform the Employment Bank authority% the $1& concerne" in
case / cease to conform to the eli>ibility criteria of the scheme in the interim perio".
(+ull $i>nature of the Applicant)
For official Use only
7he application of $ri%$mt@@@@@@@@@@@@@@@.bearin> Enrolment No. ...@@@@@for
!nemployment Assistance un"er this scheme has been :erifie" an" the same is bein> sanctione"
subAect to further :erification of his%her eli>ibility from time to time.
1ate:
($i>nature .ith seal)
$ub=1i:isional &fficer @@.........@@@. %
Boint 1irector of Employment9 Colkata