PARADIP REFINERY

EMPLOYEES CONSUMER
COOPERATIVE SOCIETY
REGD NO -203/JS

SHOP NO 18 IOCL MARKET COMPLEX ,PARADIP

EMAIL-PRECCSINDIANOIL@GMAIL.COM

NAME :

EMPLOYEE ID :

DATE OF BIRTH :

CATEGORY : GENERAL SC ST OBC

EMAIL ADDRESS :

CONTACT NO :

WHATSAPP NO :

CORRESPONDENCE ADDRESS :

RESIDENTAL ADDRESS :

FATHERS NAME :

NOMINEE NAME :

NOMINEE'S AGE :

NOMIEE'S ADDRESS :

NOMINEES CONTACT NO :

RELALTIONSHIP WIH NOMINEE :

BANK ACCCOUNT NO :

BANK IFSC CODE :

MEMBERSHIP STATUS : NEW MEMBER EXISITING MEMBER

ADMISSION & MEMBERSHIP FEES :

CAPITAL TO BE INVEST ( IN RUPEES) :

I DO HERE BY CERTIFIED THAT THE DATA I SHARED WITH PRECCS THROUGH THIS ONLINE FORM IS
TRUE AND CORRECT IN MY KNOWLEDGE AND BELIEF.

SIGNATURE