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Online Registration of Member
1 Member Name * *
2 Father's Name * *
3 Category * *
4 Sex * *
6 Date of Birth * (DD/MM/YYYY) * Date of Appointment * (DD/MM/YYYY) *
7 Employee/Personnel no.
Appointment Letter (PDF less than 1MB)
Aadhar Card (PDF less than 1MB)
8 Aadhar Card no.
9 Name of Company/Subsidiary*
10 Name of Unit/Colliery*
11 Registration No of Unit/Colliery*
12 Identification Mark * *
13 Saving Bank Account Number * *
14 Bank Name * *
15 Bank Branch * *
16 Bank IFSC * *
17 10 Digit Mobile Number * *
18 Email-Id
19 Dependent Count     ADD ROW /REMOVE ROW
 
 
NOMINATION(%)
SL.
NAME
RELATIONSHIP
DATE OF BIRTH
PROVIDENT FUND
PENSION(If no Family Member Alive)
1
Scanned Image of Nomination Form (DA,PS-3,PS-4) (PDF less than 5MB)
20  Present Address Copy Address Permanent Address
 
Address1 * *
Address 2
Post * *
District * *
State * *
Pin * *
Address1
Address 2
Post
District
State
Pin
 
* All marked Fields are mandatory