FORM-V

[See sub-rule(1) of rule 20]

Application for Registration as a Beneficiary
Passport
size Photo

To
The Secretary,
Karnataka Building and Other Construction
Workers Welfare Board,

Bangalore-560……
1 Full name and permanent :
address of the applicant:

2 Date of birth/age :
3 Sex : Male/Female
4 Nationality :
5 Whether belongs to : SC/ST/OBC/Others
6 Local address :

7 Name and address of the :

present employer

8 Nature of work :
9 Date of employment :
10 Wages per day/per month :
11 Name of the nominee & :
relation with address

12 Other three members of family :

Name & age

I hereby declare that the above information is true and correct to

the best of my knowledge and belief.

Place:
Date: Signature/Left Hand Thumb Impression of
the Applicant

for office use only

Place:
Date: Received fee of Rs………..
Application accepted/rejected

Signature of the Registering Officer

with seal