Tracking no : MAY/RN/AC/2024/010911

ODISHA BUILDING AND OTHER CONSTRUCTION WORKERS' WELFARE BOARD,

BHUBANESWAR.

Annual Contribution Form

1. First Name : KAMAL LOCHAN MANDAL

2. Sur Name :

3. Sex : Male

4. Aadhaar number : 224318614612

5. BOC ID : ODMBJ001012425

(a) Date of Registration : :

6. Details of the establishment(s)

(a) Name of Establishment / Employer : AJAY BEHERA

(b) Establishment Sector : Private

(c) Establishment Address : ASTAGADIA, GADIGHATI ,Gadighati, Gadighati,

MAYURBHANJ, ODISHA, 757055

(d) Contact number : 7205729954

(e) Registration number :

(f) From : 01/01/2024

(g) To : 01/05/2024

(h) Employment certified by : Self certification

7. Period of Annual Contribution :

(a) Period of Annual Contribution From : 15/05/2022

(b) Period of Annual Contribution To : 15/05/2025

Declaration by the applicant

I hereby declare that all the details entered are correct and I accept that my renewal will be revoked if found
otherwise.