Form No. “ORISSA MEDICAL LABORATORY TECHNICIANS' ASSOCIATION (Recognised by Home Deptt. Vide L. No. 1505Assn. dt. 4.3.1983) FOUNDATION DATA OF MEMBER OF OMLTA affix atlested recent Registration No. ] I passport size (to be assigned by the Board of MLT&MRT) photograph 01 Name (in BLOCK Letters) 02 Fathers / Husband's Name 03. Designation 04 Date of Birth (words (en fgures) 05 Qualfication (s) 06 Category Gen ‘| se [_] st | seBC 07 Present Status EMPLOYED oO UNEMPLOYED RETIRED 08 +. Date of fist appointment as LT (as mentioned in Service Book) Date of Joining in Cadre 1m Date of Joining in Promotional Post : 09. PresentAddress 2 IN Code, PS. 10. Permanentaddress" 12 13 14 15 18 19 20 Ne Place Tel No a) Name of the Institution in which waned b) From where passec Year of Training Month & year of passing Posting Adgress PPC. No. of Retd. persons Present pay Date of next increment Attach attested xerox copy of HSC/ +2Sc Training certificate / Certificate from D.D O. / PPO for retired personel Bonafide membership No (to be assigned by OMLTA) Change of correspondence. MUT. Land No. with STD Code, Mobile No ‘address. Tel. No. (Mobile & Land) to be intimated immediately, In all future correspondences please quote B.M. No. (Bonafide Membership No.) and Regd. No. of Board of SELF DECLARATION The information given by me in this form and enclosures is true and | am solely responsible for accuracy and liable for any false and fabricated information. GENERAL SECRETARY Full signature of applicant OMLTAFEE STRUCTURE FOR BONAFIDE MEMBERSHIP OF O.M.L.T.A. {ODISHA MEDICAL LABORATORY TECHNICIANS’ ASSOCIATION) S.N. PARTICULARS FOR DMLT FOR MLT APPLICANTS | APPLICANTS 01 _| MEMBERSHIP REGD. FEES Rs. 300 /- Rs. 105 /- 02 _| REGISTATION PROCESSING FEES. So Rs.100/- | 03 _| FINE (if he / she failed to be a MEMBER before Dt. 31.12.1996) = Rs, 100 f- 04 | MEMBERSHIP FEES from Joining year up to Dt. 31.12.1995 = @ Rs. 10/-peryr. (05 _| MEMBERSHIP FEES from Dt.1.1.1996 to Dt. 31.12.2007 _| @ Rs. 20 /- per year 06 | MEMBERSHIP FEES from Dt.1.1.2008 to Dt. 31.12.2010 | @ Rs. 60 /- per year 07__| MEMBERSHIP FEES from Dt.1.1.2011 to Dt. 31.12.2018 @ Rs. 100 /- per year 08 | REGD. PROCESSING CHARGES FOR MLT / DMLT Rs, 100 /- CANDIDATE REQUISITE DOCUMENTS FOR MEMBER OF BONAFIDE MEMBERSHIP FOR OMLTA 1. Application Form of OMLTA, which will be obtained from Gen. Secy., Oma fiesta 2. Pass port sized Photographs : 2 Nos. 3. Xerox copy of HSC Certificate : 2 Nos. 4. Xerox copy of CHSE Certificate : 2 Nos. 5. Xerox copy of DMLT / MLT Certificate : 2 Nos. 6. Xerox copy of Employee Certificate : 2 Nos. (FORMAT), EMPLOYEE CERTIFICATE This is to certify that Sri / Smt. / Miss ... Js working as Jr. Laboratory Technician / Sr. Laboratory Technician / Contractual Laboratory Technician in this establishment since Dated and as per his / her service record, the date of appointment / engagement Is .... .. He / she has successfully completed and passed from one Medical College of Odisha / any AICTE approved Institution of India. Signature with Date and seal of the D.D.0.