labour.gov.in. .docx · Web viewhas in the dispensary / hospital the equipments for which grant-in-aid is being proposed (2) were these purchased by grant-in-aid from L.W.O (3) if

FORMS

Form scheme no. 2HEALTH

ANNEXURE ‘A’ DOCTOR’s CERTIFICATE

This is to certify that Shri/Smt. __________________________________ husband/wife of _________________________________ whose signature/LTI is appended below has undergone sterilization operation successfully on _______________ at ________________________ ________________________ (Name of the Medical Institution). I recommended that monetary compensation of Rs.200/- may please be paid to him/her from the Beedi Iron Ore Manganese Ore and Chrome Ore, Limestone and Dolomite Mine and Cine Workers Welfare Funds of the Labour Welfare Organisation.

Signature ____________________

Signature/LTI Name of the Doctor _____________ (Seal)

Shri/Smt. ____________________

ANNEXURE „B‟ Application Form for payment of Monetary Compensation for Sterilization.

1. Name of the applicant: Shri/Smt. _________________________________ 2. Wife/Husband of : Shri/Smt. _________________________________ 3. Identity Card No. _____________________________________________ 4. No. of living children of the applicant. 5. Date of sterilization. 6. Name of Medical Institution where sterilization operation was conducted.

(i) It is requested that Monetary Compensation @ Rs.200/- may be sanctioned to me for having undergone sterilization operation at __________________________________________________.

(ii) A certificate issued by the aforesaid medical institution is enclosed herewith. (iii) I undertake that I shall refund the said compensation if at any stage it is proved that it

is false claim.

_____________________________ Signature/Thumb impression of the Applicant/Iron Ore, Limestone and Dolomite/ Cine Workers.

Date: ___________________ Countersigned by Employer.

Scheme no. 3ANNEXURE-I

APPLICATION FORM FOR THE PAYMENT OF LUMP SUM GRANTS OF Rs.1000/- TO FEMALE WORKERS UNDER THE MATERNITY BENEFIT SCHEME FOR FEMALE BEEDI, IMC, LSDM AND CINE WORKERS.

1. Name of the applicant :

2. Address :

3. Wife/Daughter of :

4. Identify Card No. :

5. Date of delivery :

It is requested that the lump sum grant of Rs.1000/- may kindly be sanctioned to me. Following certificates are enclosed:-

i)Birth Certificate of the Child born.

ii) Certificate to the effect that I am a beedi, IMC, LSDM and Cine Worker.

The certificate shows that I have been a beedi, IMC, LSDM and Cine Worker for

at least six months before the delivery.

iii) Certificate to the effect that the benefit is being claimed for the first/second time.

I understand that I shall refund the said amount if it is proved that it is a false claim.

Dated: __________________ Signature/Thumb impression of the Applicant

Recommendation of the Medical Officer Incharge of the nearest dispensary of the Labour Welfare Organisation.

Medical Officer Incharge

ANNEXURE-II

This is to certify that Smt. __________________________________________ wife/daughter of Shri _________________________________________________ is a beedi/IMC/LSDM/Cine Worker. She is employed with ______________________ as on date and has been engaged in beedi making/working as IMC/LSDM/Cine Workers for the last ________________ year(s) and ____________________ month(s).

** According to her statement which is enclosed. Her employer as per her statement has refused to issue her the employment certificate. Her Identity Card No. is ___________________________.

______________________________ Signature of Employer/Gazette Officer of the Labour Welfare Fund Organisation/medical Officer Inchargeof the nearest dispensary of the Labour Welfare Organisation.

Dated _____________________ ** This may be deleted in case the employer signs the certificate.

Scheme no.4Annexure-I

FORM „A‟ Application form for financial assistance for Heart surgery or allied treatment.

To

The Welfare Commissioner, Labour Welfare Organisation, ----------------------------------- Sir,

I hereby apply for financial assistance for undergoing Heart Surgery or allied treatment in ___________ mention the name of the hospital where the Medical Officer, Labour Welfare Organisation, has recommended the treatment. In this connection, I submit my particulars as under:-

1. Name of the Applicant in Full: (In Block Letters)

2. Name and address in full of the Mine/Beedi establishment/BeediContractor/Agent

3. The date of his/her employment and total continuous service.

4. Designation or the nature of His/Her Employment.

5. His/Her monthly salary/wages (Excluding bonus)

6. (a) Identity Card No. in case ofBeedi/Cine Workers.

(b) „B‟ Register No. in case of Mine Worker.

Signature of Mine/Beedi/Cine worker

Name: Place: Date:

Certificate by the Mine Manager/owner and in case of beedi worker by owner of Establishment/Contractor/Agent.

It is certified that Shri/Smt/Kum ______________________________________ is employed in this mine/Beedi Establishment by me as ______________________ continuously with effect from __________________________________ and information furnished by him/her as above are correct.

Signature: Designation: Name & Address of the Mine/BeediManagement/Contractor.Date: Seal of the Mine/Beedi Establishment

COUNTERSIGNED BY THE owner/Manager of the Beedi Establishment if the worker is working under Contractor/Agent.

Date: OWNER/MANAGER Name: Designation: Address:

CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO.

Certified that I have carefully examined Shri /Smt/ Kumari ________________________ __________________ and found him/her suffering from _____________________ disease. In my opinion, his/her admission in the ________________ hospital which is recognized by the Govt. of ________________________ is absolutely necessary for Kidney Transplantation or allied treatment.

His/Her Identity Card No. is ______________________________/ „B‟ Register No. is _____________________________________

Signature: Name: Designation: Name of the Dispensary/Hospital Dated:

FORM „B‟

Application for grant of subsistence allowance from the Labour Welfare Organisation under the Scheme for Financial Assistance to Mine/Beedi/Cine workers suffering from heart diseases.

To

The Welfare Commissioner, Labour Welfare Organisation.

Sir,

I hereby apply for financial benefits under the scheme for “financial assistance to mine/beedi and cine workers for ___________ I have undergone treatment for ________________ in _________________________ (mention the name of the hospital where the treatment has been taken). I furnish my particulars as under: -

1. Name of the applicant in full:

2. Date of birth/Age:

3. Full postal/residential address of the applicant

4. Full address of the hospital where the applicant has undergone treatment

5. The reference No. and date of the letter from Welfare Commissioner permitting Him/her to undergo treatment in the above hospital.

6. Amount actually incurred by the applicant for treatment (Furnish the details with supporting billsetc, each bill has to be countersigned by the hospital authorities with seal and full signature)

a. Hospital charges including diet etc. Rs.

b. Expenses for pre post operation Check ups: Rs.

c. Charges for heat valve etc, which were required to be purchased fromhospital/market (prescription slips to be enclosed)

Total :Rs.

7. Amount claimed as bus/No. of Mode of travel. AmountTrain charges Persons

a) Date of outward journey

b) Date of inward journey

I hereby declare that the particulars furnished above are correct. If any of the particulars are found to be incorrect. I realize that I will be liable for suitable action apart from refund of financial assistance, if any received by me.

Signature of the Mine/Beedi worker Place :Date :

Certificate by the Management

It is certified that Shri/Smt/Kum. ______________________________ is employed in this Mine/Beedi Establishment by me as ___________________ (mention designation) and that his/her wage is __________________________ p.m.

It is certified that no wages have been paid to Shri/Smt/Kum. __________________________ for the period of his/her treatment from ______________ to __________________.

His/her Identity Card/‟B‟Reg. No. is ________________________________

Signature: Designation:

Name & Address of the Beedi/Mine management:

Date:

Certificate of the superintendent of the Hospital

Certified that Shri/Smt/Kum. _____________________ who is employed as ____________________ in the Mine/Beedi establishment of M/S __________________________ has undergone treatment for _________________ in this hospital.

He/She was admitted in the hospital for the said purpose from ___________________ to ______________________ and was discharged on ___________________________-.

He/She needs rest for ________________________ day w.e.f. ____________________.

Signature of the Superintendent of Hospital Name: Address: Place:

Scheme no. 5Annexure-I

FORM „A‟ Application form for financial assistance for Kidney Transplantation or allied treatment

To,

The Welfare Commissioner, Labour Welfare Organisation, ………………………………

Sir,

I herby apply for financial assistance for undergoing Kidney Transplantation or allied treatment in ………………………………….. (Name of the hospital where the treatment has been recommended by the Medical Officer, Labour Welfare Organisation). In this connection, I submit my particulars as under:-

1. Name of the Applicant in Full (In Block Letters)

2. Name and address in full of the Mine/Beedi establishment/BeediContractor/Agent.


4. Designation or the nature of his/her employment.

5. His/Her monthly salary/wages (excluding bonus)

6. (a) Identity Card No. in case of Beedi Workers.


Signature of Mine/Beedi worker/Cine worker Name:

Place: Date:

CERTIFICATE BY THE MINE MANAGER/OWNER AND IN CASE OF BEEDI WORKER BY OWNER OF ESTABLISHMENT/CONTRACTOR/AGENT

It is certified that Shri/Smt./Kum. ……………………………………. Is employed in this mine/Beedi Establishment by me as ………………………………… continuously with effect from …………………………………….. and information furnished by him/her as above is correct.

Signature: Designation:

Name and Address of the Mine/BeediManagement/Contractor.

Date:

Seal of the Mine/Beedi

Establishment Countersigned by the Owner/Manager of theBeedi Establishment if the worker is working under Contractor/Agent.

OWNER/MANAGER Name: Designation: Address:

Date:

CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO

Certified that I have carefully examined Shri/Smt./Kumari ……………………

…………………………….. and found him/her suffering from ………………………..

……………… diseases. In my opinion, his/her admission in the ………………………

……………….. hospital which is recognized by the Govt. of ………………………….

Is absolutely necessary for ………………………………………………………..

His/her Identity Card No. is …………………………………………………

„B‟ Register No. is ……………………………………………………………

Signature: Name: Designation: Name of the Dispensary/Hospital

Dated: ………………

FORM „B‟Application for grant of subsistence allowance from the Labour Welfare Organisation under the

Scheme for Financial Assistance to Mine and Beedi workers for Kidney Transplantation etc.

To,

The Welfare Commissioner,

Labour Welfare Organisation, ……………………………

Sir,

I herby apply for subsistence allowance and other financial benefits under the scheme for financial assistance to mine and beedi workers for Kidney Transplantation. I have undergone treatment for ……………………………….. in ……………………… ……………………………………….. (mention the name of the hospital where the treatment has been taken).

I furnish my particulars as under:-

1. Name of the Applicant in full :

2. Date of birth/Age :

3. Full postal/residential address of the applicant :

4. Full address of the hospital where the applicant has undergone treatment :

5. The reference No. and date of the letter from Welfare Commissioner permitting him/her to undergo treatment in the above hospital :

6. Source of receipt of Kidney Name and full address of the Donor :

7. Amount actually incurred by the Applicant for treatment (Furnish the details with

supporting bills etc. each bill has to be

countersigned by the hospital authorities with seal and full signature) :

(a) Kidney charges (Donor‟s) : Rs.

(b) Hospital charges including diet etc. : Rs.

(c ) Charges for Dialysis : Rs.

(d) Expenses for pre and post operation : Rs. Check ups :Rs.

______________

Total :Rs.

8. Amount claimed as Mode of travel No. of personsAmount

bus/train charges

(a) Date of outward Journey:

(b) Date of inward Journey:

I hereby declare that the particulars furnished above are correct. If any of the particulars

are found to be incorrect, I realize that I will be liable action for suitable action apart from

refund of financial assistance, if any received by me.

Signature of the Mine/Beedi worker

Place:

Date:

CERTIFICATE BY THE MANAGEMENT

It is certified that Shri/Smt/Kum/ ……………………………… is employed in this

mine/Beedi Establishment by me as …………………………….. ( mention designation)

and that his/her wage is ………………………… p.m.

It is certified that no wage have been paid to Shri/Smt/Kum. …………………….

…………………….. for the period of his/her treatment from ……………………….. to

…………………….

His/her Identity Card/‟B‟ Reg. No. is ………………………………………..

Signature

Designation

Name & address of the

Beedi/Mine management.

Certificate of the Superintendent of the Hospital

Certified that Shri/Smt./Kum. ……………………………………… who is employed as

………………………………………… in mine/Beedi establishment of M/s

…………………………………………………… has undergone Kidney transplantation and

treatment/allied treatment in this hospital.

He/She was admitted in the hospital for the said purpose from …………………

……………… to and was discharged on ………………………………….. He/She needs rest for

…………………………….. daysw.e.f. ……………………………..

Signature of the Superintendent of Hospital

Name

Address

Place:

Scheme no. 6

FORM „A‟Application form for financial assistance for domiciliary treatment of minor diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases.

To

The Welfare Commissioner, Labour Welfare Organisation, ………………………………

Sir,

I hereby apply for financial assistance for undergoing domiciliary treatment of minor diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases in………………………………….. (Name of the hospital) where the treatment has been recommended by the Medical Officer, Labour Welfare Organisation. In this connection, I submit my particulars as under:-

7. Name of the Applicant in Full ( In Block Letters)

8. Name and address in full of the Mine/Beedi establishment/BeediContractor/Agent.



11. His/Her monthly salary/wages (excluding bonus)

12. (a) Identity Card No. in case of Beedi Workers.


Signature of Mine/Beedi worker/Cine worker

Name:

Place:

Date:

CERTIFICATE BY THE MINE MANAGER/OWNER AND IN CASE OF BEEDI

WORKERBY OWNER OF ESTABLISHMENT/CONTRACTOR/AGENT

It is certified that Shri/Smt./Kum. ……………………………………. Is employed in this

mine/Beedi Establishment by me as ………………………………… continuously with effect

from …………………………………….. and information furnished by him/her as above is

correct.

Signature:

Designation:

Name and Address of the Mine/Beedi

Management/Contractor.

Date:

Seal of the Mine/Beedi

Establishment

Countersigned by the Owner/Manager of the Beedi Establishment if the worker is

working under Contractor/Agent.

OWNER/MANAGER

Name:

Designation:

Address:

Date:

CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO

Certified that I have carefully examined Shri/Smt./Kumari ……………………

…………………………….. and found him/her suffering from ………………………..

……………… diseases. In my opinion, his/her admission in the ………………………

……………….. hospital which is recognized by the Govt. of ………………………….

Is absolutely necessary for ………………………………………………………..

His/her Identity Card No. is …………………………………………………

„B‟ Register No. is ……………………………………………………………

Signature:

Name:

Designation:

Name of the Dispensary/Hospital Dated: ………………

FORM „B‟Application for grant of subsistence allowance from the Labour Welfare Organisation under the

Scheme for Financial Assistance to Mine and Beedi workers for domiciliary treatment of minor

diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases.

To,

The Welfare Commissioner,

Labour Welfare Organisation,

…………………………… Sir,

I herby apply financial benefits under the scheme for financial assistance to mine and

beedi workers for …………………………… I have undergone treatment for

………………………… (mention the name of the hospital where the treatment has been

taken).

I furnish my particulars as under:-

8. Name of the Applicant in full :

9. Date of birth/Age :

10. Full postal/residential address of the applicant :

11. Full address of the hospital where the applicant has undergone treatment :

12. The reference No. and date of the

letter from Welfare Commissioner permitting

him/her to undergo treatment in the above

hospital. :

13. Amount actually incurred by the Applicant for treatment (Furnish the details with

supporting bills etc. each bill has to be

countersigned by the hospital authorities

with seal and full signature) :

(a) Hospital charges including diet etc. : Rs.

(b) Expenses for pre and post operation

Check ups:Rs.

______________

Total :Rs.

I hereby declare that the particulars furnished above are correct. If any of the

particulars are found to be incorrect, I realize that I will be liable action for suitable action

apart from refund of financial assistance, if any received by me.

Signature of the Mine/Beedi worker

Place:

Date:

CERTIFICATE BY THE MANAGEMENT

It is certified that Shri/Smt/Kum/ ……………………………… is employed in this

mine/Beedi Establishment by me as …………………………….. ( mention designation)

and that his/her wage is ………………………… p.m.

It is certified that no wage have been paid to Shri/Smt/Kum. …………………….

…………………….. for the period of his/her treatment from ……………………….. to

…………………….

His/her Identity Card/‟B‟ Reg. No. is ………………………………………..

Signature

Designation

Name & address of the

Beedi/Mine management.

Date

Scheme no. 7Application Form for seeking financial assistance for marriage of daughter by

widow of beedi/mine/cine worker

1. Name of the applicant ____________________________

2. Name of the deceased worker and her/his ____________________________ relationship with the applicant

3. Name of the daughter for whose marriage ____________________________ assistance is sought

4. Name of employer/establishment where the _____________________________ beedi/mine/cine worker was working at the time of his death

5. Date of joining the establishment _____________________________

6. Date of death of the worker _____________________________

7. Details of family members of the deceased beedi/mine/cine worker (enclose copy of Identity Card as proof)

8. Name and address of bridegroom ______________________________________ _________________________________________________________________ 9. Date of marriage (enclose copy of invitation card) _________________________

Declaration: I solemnly declare that the above particulars are correct the best of my knowledge and belief and in the event of any of the above statements found incorrect. I will return the full amount of financial assistance of the Welfare Commissioner.

Place:

Signature of applicant Date:

SI. NoNameRelationship with the workerDate of birth1.2.3.4.

Scheme no. 8FORM OF APPLICATION FOR GRANT OF SUBSISTENCE ALLOWANCE TO DEPENDANTS OF MINE/BEEDI/CINE WORKERS UNDER THE DOMICILIARY TREATMENT OF T. B. SCHEME.

1. Name in full of the workers

2. Name and address in full of the mine/beedi establishment where the worker is employed.


4. The date of his/her employment and period of service at the Mine /BeediEstablishment before contacting T.B.

5. His/her monthly salary/wages (excluding bonus)

6. If he/she (patient) is getting any financial assistance from any mine management/beediestablishment or from any source. If so, state amount with the period.

7. Number of dependants of the Mine/Beedi worker (patient) (Dependants include wife/ husband, unmarried children and step children residing with and whollydependant on the worker)

8. Name, age, marital status and relationship of each dependant.

9. Name and address of the dispensary/hospital where the worker is being treated.

10. A certificate that the patient is the only earning member of the family and has no other source of incomefrom Mine Manager/Beedi Establishmentor from District Magistrate or any gazetteofficer authorized by himor by the Headman of village Panchayat.

11. Certificate of the Manager of Mine/Beedi Establishment/ District Magistrate/Headmanof village.

Certified that the statement made by the applicant against items 1 to 8 have been verified and found to be correct.

Manager/Agent/Owner of Mine/Beedi Establishment

2nd certificate of the medical authority.

Certified that the statement of the applicant against item 9 is correct. He/she is/has been receiving regular treatment from this dispensary/hospital.

Signature Designation Official Stamp.

APPLICATION FORM FOR CLAIMING TREATMENT

CHARGES BY MINE/BEEDI/CINE WORKERS UNDER

THE DOMICILIARY TREATMENT OF T.B. SCHEME

1. Name in full of the worker

2. The name and address in full of the mine/beedi establishment where the worker is employed.

3. Date of his/her employment and the total continuous service in the mine/beedi establishment.

4. Designation or the nature of his/ her employment.

5. His/her monthly salary/wages (Excluding Bonus)

6. The Dispensary/Hospital where the worker is undergoing Domiciliary treatment for T.B.

Signature Date: Name

ATTESTATION OF THE MANAGER/OWNER

It is certified that Shri /Smt.____________is employed in this mine/establishment as _____________continuously for _______________years months. It is certified that the statement made by the applicant against cols. 1 to 6 above have been verified and found to be correct.

Signature

Manager/Owner

Name & Address of Date: SEAL the Establishment.

CERTIFICATE OF THE MEDICAL OFFICER

Shri_____________________employed in_______________mine / establishment and whose signature/thumb impression is given hereunder, was examined by me on____________________and was found to be suffering from T.B. According to my opinion, he/she has to receive regular domiciliary treatment for T.B.

Date SEAL Signature Name

Scheme no. 9FORM OF APPLICATION FOR OBTAINING SPECTACLES FROM THE LABOUR WELFARE ORGANISTAION.

1. Name :

2. Father‟s Name :

3. Age :

4. Sex :

5. Name of the Mine/BeediEstablishment/Contractor /Agent where employed at present. :

6. Name of the owner of the Mine BeediEstt./ Contractor/ Agent. :

7. Designation. :

8. Date of appointment :

9. Mine/BeediEstt./ Contractor in which he has worked in the past with approximate month & year. :

10. Wages received per month :

11. Does he/she already wear the Spectacles?: Date: _____________ _____________________

Signature of the applicant.

CERTIFICATE OF MANAGEMENT/CONTRACTOR / AGENT

S.No.

Name of Mine/BeediEstt./Contractor/ Agent.

B.R.No.

Period From

Period To

Total Service.

Signature of the Manager/Contractor/ Agent in token of having certified the service period.

12. Service rendered from time to time

It is further certified that he/she gets Rs. ______________ (In words Rupees ___________________________) exclusive of bonus, per month and his economic condition is so poor that he/she cannot purchase a Spectacles. He/she deserves providing of Financial Assistance for Spectacles.

Date: ________________ Name of Manager/Owner/Contractor Agent.

Seal of Management.

CERTIFICATE OF MEDICAL OFFICER OF THE ORGANISATION

It is certified that I have examined Shri/Kum./Smt. _______________________ S/o, D/o of ________________________ employed ____________________________ carefully and have come to the conclusion that he/she need corrective lenses to improve his/her vision. The case deserves further examination by an Eye Specialist. He/She is, therefore, referred to ______________________________________(Name of the Hospital is to be given) or ____________________________________(Qualified Private Eye Specialist).

Name _____________________ Date: ___________ Designation _________________

Seal

CERTIFICATE OF THE EYE SPECIALIST

Certified that I have examined Shri/Kum./Smt. ____________________________ S/D/W of ____________________________ aged _________ Sex ______________ carefully and allot the vision/lenses number is under:-

Right vision Left vision

I further suggest that the patient should continue to take the following treatment for a period of __________________________ after this he/she should attend the hospital/clinic on for re-check.

Date: _____________ Medical Officer / Eye Specialist SEAL

Scheme no. 10FORM OF APPLICATION

1. Name in full of the worker:

2. The name and address in full of the Mine/Beedi Establishment employed.

3. The date of his employment and the total continuous service in the Mine/Beedi Establishment.

4. Designation or the nature of his employment.

5. His monthly salary/wages (excluding bonus).

6. The Hospital where admission is sought.

7. Whether he was admitted previously under this Scheme. If so, give date and the period of his stay and the name of the Hospital.


`FORM OF APPLICATION

1. Name in full of the worker:

2. The name and address in full of the Mine/Beedi Establishment employed.

3. The date of his employment and the total continuous Service in the Mine/Beedi Establishment.

4. Designation or the nature of his employment.

5. His monthly salary/wages (excluding bonus).

6. The Hospital where admission is sought.

7. Whether he was admitted previously under this Scheme. If so, give date and the period of his stay and the name of the Hospital.


ATTESTATION OF THE MINE MANAGER/OWNER

It is certified that Shri/Smt ………………………………… is employed in this mine as ………………………. Continuously for ……………………… years ……….. months and to the best of my knowledge and information the particulars give above by him/her are correct.

Date Seal Signature Mine Manager/Owner Name and address of the

mine

CERTIFICATE OF THE MEDICAL OFFICER

Shri ……………………………….. employed in ………………………. Mine and whose signature/thumb impression is given hereunder, was examined by me on ………………. And was found to be suffering from ……………………… accordingly to my opinion his admission the mental Hospital/MansikArogyashala is not absolutely necessary for ……………………..months/days.

Date Seal Signature Name

FORM OF REGISTER TO BE MAINTAINED IN HOSPITALS WHERE

MENTAL PATIENT HAVE BEEN ADMITTED

SI. No.

Name of the worker

Nature of employme

nt.

Name of the mine

Date of admissio

n

Nature of

sickness

Duration of

retention

Complete or

partial recovery

Date of discharg

e.

Signature of the

doctor

Remarks.

Scheme no11.FORM – „A‟

APPLICATION FOR TREATMENT OF MINE/BEEDI/CINE WORKERS SUFFERING FROM CANCER

1. Name in full of worker.

2. Name & Address in full of mine/beedi establishment.

3. Name of patient.

4. Age and relationship with the worker.

5. Date of his/her employment and the total continuous service.

6. Designation of the nature of his/her employment.

7. His/her monthly salary/ wages (excluding bonus).

8. The hospital where treatment is sought.

9. Whether the applicant/ dependent had undergone treatment forCancer previously? If so, mention the duration of the treatment.

Signature Date : Thumb impression

(Name in Block letters)

ATTESTATION BY THE PRODUCER/OWNER OF THE FILM INDUSTRY

Certified that Shri/Smt./Kum.-----------------------------------------is employed in this Industry as continuously wef----------------------------------------and information furnished by him/her above is correct to the best of my knowledge and belief.

Signature: Designatioj with seal

Seal of the Film Indurstry/owner

Place------------- Date--------------

ATTESTATION BY THE MANAGER / OWNER OF THE MINE/BEEDI ESTABLISHMENT

Certified that Shri/Smt./Kum. ________________________________ is employed in this mine/beedi

establishment as ___________________________ continuously w.e.f. _________________________

and information furnished by him/her above is correct to the bet of m knowledge and belief.

Signature Place: ________

Designation with Seal Date: ________

Seal of the Management Beedi establishment.

CERTIFICATE BY THE MEDICAL OFFICER OF THIS ORGANISATION

Certified that Shri/Kum ………………………………………… employed in

………………………… and whose signature/thumb impression is given here

under was examined by me on ……………………………. and found to be

sufferingform cancer. According to my opinion his/her admission/treatment in a

recognized. Cancer Hospital is absolutely necessary for a period of

…………………………… months.He/She is, therefore, referred to

……..……………………………………. (Name of the Cancer Hospital to be

furnished). OR

Certified that Shri/Smt./Kum ………………………………………………..

Wife/son/daughter/father/mother of …….…………………………………………

employed in ……………………………………. and whose

signature/thumb

impression is given here under was examined by me on

…………………………………………. and found Hospital is absolutely

necessary for a period of ………………………………… months. He/She/is,

therefore referred to ………………………………………….. (Name of the

Cancer Hospital to be furnished).

Signature Name & Designation Date …………Seal

CERTIFICATE OF THE MEDICAL OFFICER OF THE RECOGNISED CANCER HOSPITAL

Certified that Shri/Smt./Kum ……………………………………………………

who is employed as …………………………………………………….. in the

mine/beedi establishment has been carefully examined and found to be

suffering from Cancer, according to my opinion his/her admission/treatment in

one of the Cancer Hospital is absolutely necessary for a period of

……………………………….. (Approximately).

Or

Certified that Shri/Smt./Kum ….…………………………………………….

wife/son/daughter/father/mother of

……………………………………………… who is employed as

………………………………………….. in the mine/beedi establishment of

…………………………………….. has been carefully examined and found to

be suffering from cancer. According to my opinion his/her admission/treatment

in one of the Cancer Hospital is absolutely necessary for a period of

………………………………… (Approx).

Signature Date …………………

Name & Designation

Seal

Form – “B” APPLICATION FOR CLAIMING REIMBURSEMENT OF EXPENDITURE

TREATMENT OF CANCER

To,

The Welfare Commissioner, Labour Welfare Organization, _______________________

Sir,

I hereby apply for reimbursement of expenditure for the treatment of

cancer, I/my wife/son/daughter/father/mother have/has undergone

treatment for cancer in …………………………………….. (Mention

name of hospital where the treatment has been taken).

1. Name of the applicant in full (In block letters)

2. Date of birth and age

3. Full address of the applicant

4. Name of the patient

5. Age and relationship with the worker

6. Name and address of the

Mine management/BeediEstt./ in

which he/she employed.

7. Date of continuous employed

in the Mine/Beedi Establishment Showing the total continuous service.

8. Is the applicant‟s wife or husband employed in the Mine/Beediestablishment? Give details.

9. Full address of the hospital where the applicant/dependenthas undergone treatment for cancer.

10. Please quote reference number date of the Welfare

Date of welfare

Commissioner in which he/she permitted to undergo treatment in the above hospital.

11. Amount claimed as subsistence allowance showing the duration of the claim.

12. Amount actually incurred/claimedby the applicant for medicines, Furnishdetails with supporting vouchers/bills etc.

13. Amount actually incurred/claimedby the applicant on diet, furnish detailswith supporting bills etc.

14. Amount claimed as bus/train charges.

15. Amount claimed as D.A.

I hereby declare that the particulars furnished above are correct to the best

of my knowledge and belief. If any of the particular is found to incorrect,

I realize that I will be liable for suitable action a part form refund of

financial assistance received by me. Place : Signature of the applicant or thumb impression

Date : (Name in block letters)

CERTIFICATE BY THE MEDICAL OFFICER OF THE RECOGNIZED CANCER HOSPITAL

Certified that Shri/Smt./Kum.

…………………………………………………… who is employed as

…………………………………………………… in the Mine/Beedi

Establishment of ……………………………… has undergone treatment

in this hospital as in-patient/out-patient for cancer with effect form

…………………………………

OR Certified that Shri/Smt./Kum. …………………………………

wife/son/daughter/ father/mother of Shri/Smt./Kum.

……………………………………… who is employed as

……………………..……………………………… in the Mine/Beedi

Establishment of

……………………………………………………………… has

undergone treatment in this

…………….……………………………………………… hospital as in-

patient./ out-patient for cancer with effect from …………………… to

……………………..

Signature of the Medical Date ……………

Officer of the Hospital

Designation & Seal

CERTIFICATE OF THE MANAGEMENT

Certified that Shri/Smt./Kum. ……...………………………………… is employed in the

Mine/Beedi Establishment as …………………………………………… (mention

designation) and that his/her wage is …………………………. Per month.

Certified that Shri/Smt./Kum. ….……………………………………………… is working

in this Mine/Beedi Establishment/Producer/Owner since ……………….

Certified that no wage has been paid to Shri/Smt./Kum. ………………………… for the

period of his/her treatment from …………………………. To ……………………

Designation with Seal

Seal of the Mine/BeediDate :

Establishment

Scheme no. 12

APPENDIX-1 LEPROSY DISEASE

Application for grant of subsistence allowance to dependants of such mine / beedi workers who happen to be the only earning member of the family having no other source of income and who are suffering from leprosy and undergoing treatment as in patient or out patient in recognized hospitals / clinics / dispensaries and are receiving regular treatment from a medical authority approved by the welfare commissioner, labour welfare fund organization.

1 Name and address of the mine / beedi workers applicant. 2His / Her designation or the nature of his / her employment. 3 Name and address of the mine / beedi establishment where he / she was working before being attacked with leprosy. 4 His / Her monthly salary / wages (excluding bonus) prior to being attacked with leprosy. 5 The date of his / her employment. 6 If He / Her (patient) is getting any financial assistance from the mine management / beedi establishment or from any source. If so state amount with period. 7 Number of dependants of the mine / beedi worker (dependants include wife / husband / unmarried children and step children residing with and whollydependant on the worker) 8 Name, age, marital status and relationship of each dependant. 9Name and address of the leprosy hospital / clinic / dispensary where the worker is being treated. 10 Name of owner of the leprosy hospital / clinic / dispensary in question 11 Is He / She being treated as indoor or out doorpatient12 In case as out door patient whether under treatment of a medical authority approved by the welfare commissioner, labour welfare fund organization. 13 A certificate that the patient is the only earning member of the family and has no other source of income from manager, mine / beedi establishment or from district magistrate or any gazette office or by the headman of a villagepanchyat in case dependants reside in a village. 14 Certificate of the manager, mine / beedi establishment / district magistrate / headman of village panchayat.

Certified that the statement made by the applicant against item1 to 8 have been verified and fund to be correct.

Manager / Agent / Owner of the mine/ Beedi Establishment.

2nd certified of the medical authority.

Certified that the statement of the applicant against items 9 to 11 is correct. He / She is / has been receiving regular treatment as out door patient

in this leprosy hospital / clinic / dispensary with effect from-------------------------and the treatment is likely to continue up to--------------------

Certified that his / her application for grant of diet allowance was not recommended before and he has not received diet allowance from the labour welfare fund.

He / She is under treatment of Dr.------------------------------- approved by the welfare and cess commissioner labour welfare fund.

Signature-------------------

Designation----------------

Official stamp------------- Date----------------

If it is subsequently found that any statement made by the applicant is wrong no claim will be entertained.

Signature or thumb impression of the applicant.

1st certificate of the manager of mine k/ beedi establishment / district magistrate / headman of village panchayat:-

Certified that to statements made by the applicant against items 1 to 8 have been verified and found to be correct. The statement against item 13 also verified by inquiry and found to be correct.

Manager / Agent / Contractor

Scheme no.13To

The welfare commissioner, Government of India, ministry of labour, Labour welfare organization,

Sub: Sanction of Grant-In-Aid for maintenance of our dispensary / services, for the calendar year --------- Sir,

We are maintaining a dispensary / hospital for mine workers and their families. You are requested to kindly sanction annual grant-in-aid for the calendar year- --------- for maintenance of our dispensary / hospital.

2 We are giving following particulars:-

(1) Name and address of the mine. (2) (i) Whether there is a separate dispensary for mine workers and their families.

(ii) (a) if there is separate dispensary for mine workers and their families furnish the following information:- Total No. of mine workers and their family members given treatment during the calendar year i.e.; January to December,---------- (b) If there is common dispensary for mine workers, factory workers, officers and supervisors including their families, please furnish the following particulars:- (i) No. of mine workers and their family members given treatment during the calendar year i.e.; from January to December, ----------. (ii) No. of factory workers and their family given treatment during the calendar year i.e.; from January to December,-------- (iii) Total No. of supervisors and officers of

factory and mine including their family members who were given treatment during the calendar year i.e.; January to December, -------

3 (a) Whether the dispensary gives treatment to members of general

public. (b) (i) If yes, whether medicines are given to members of general public (ii) total No. of members of general public given treatment including medicines during the calendar year from 1st January to 31st

December, ------ 4 Percentage of patients treated:- (a) Mine workers and their family members (b) Factory workers / supervisors / officers including their family members (c) General public (% to be given if medicines are issued to them) 5 No. of mine workers 6 No. of factory workers, supervisors & officers working in mine and factory (this information will be given if there is a common dispensary.) 7 Total expenditure incurred during the calendar year from January to December,-------:- (a) Establishment (b) Medicines (spl. Treatment + medi. Disp.) TOTAL:- 8 We are enclosing herewith the following documents:- (i) certificate of chartered accountant regarding expenditure incurred on establishment and on purchases of medicines on Performa –B (ii) Statement showing the production / consumption of limestone / dolomite and cess amount paid on the above quantity in respect of each month from January to December, ------

The above documents have been signed and stamped.

Yours faithfully,

Signature

Designation: Director (Operation)

Seal

MINISTRY OF LABOURW.V. SECTION

Check-list for proposal to the ministry for sanction of grant-in-aid in favour of the mine management for purchase of hospital equipment etc.……..1. Name and address of

the mine management.

2. Name and location of the dispensary/hospital maintained by the mine management for the benefit of their mine workers.

3 No. of mine workers/factory workers/other local people(including family members) who are allowed treatment from hospital/disp.

Mine workers Factory workers

Supervisors and officers of mines and factory

4 No. of mine worker/factory workers/other local people (including family members) treated in the hospital/disp. Three years proceeding the year in which proposal is made. i) No. of mine workers ii) No. of factory workers iii) No. of local people

Years Years Years

5 Whether treatment charges are received on the treatment of non-miners, if so, amount received during three years preceding the years in which proposal is made.

6 Cess paid by the mine management in each of the year during three years preceding the year in which the proposal is made

Years 1. 2. 3.

Years Years

7 Grant-in-aid received by the mine management scheme-wise and year wise from the Labour Welfare Organization during three years preceding the year in which the proposal is made i) Grant-in-aid for maintenance of dispensary/hosp. services ii) Grant-in-aid for Republic Day celebration. iii) Grant-in-aid for Independent Day iv)

v) vi

Years Years

8 A copy of the inspection report of the disp./hospital maintained by the mine management for the year preceding the year in which proposal is made.

9 A copy of agenda and minutes, of the S.A.C. meeting in which proposal has been recommended by SAC.

1 Name of the item(s)

0 proposed to the purchased.

11

Cost of item(s) proposed to be purchase.

12

Copy of quotation to indicate the cost of item(s)

13

Sanctioned budget grant under “Health –Grant-in-aid “during the financial year (indicate provision) made in R.E. also in case the same have been sent to the Ministry at the time of submission of the proposal.

1. Sanctioned budget grant for 2. R.E.

Rs.Rs.

14

Expending incurred out of the sanctioned budget grant/proposed R.E. under the Head "Grant-in-aid” at the time of sending the proposal.

15

Expenditure committed under the Head “Health Grant-in-aid” as in the date of submission of this proposal (indicate item-wise)

16

Balance in hand to meet the expenditure inter-alias for the proposal being sent to the Ministry.

17

Proposed manager of spending the balance provision(indicate item-

Rs.

wise) i) Grant-in-aid for maintenance of hospital/disp. Services. ii) Grant-in-aid for purchase of Ambulance Van iii) Grant-in-aid of purchase of hospital

equipments. iv)

v) vi)

Rs.

Rs.

18

Rule/scheme under which the proposal is covered

Rule 37 of the Limestone/Dolomite Mines Labour Welfare Fund Rules, 1973.

19

i) Whether the mine management has already ambulance Van ii) Where these purchased by Grant-in-aid L.W.O. iii) If yes, give reasons, as to why the management needs another ambulance Van and why grant-in-aid should be given by L.W.O.

20

i) Whether the management already has in the dispensary/hospital the equipment for which grant-in-aid is being proposed. ii) Where these purchased by Grant-in-aid from L.W.O. iii) If yes, give reasons

as to why the management further need the equipment(s) and why grant-in-aid should be given by L.W.O.

21

i) List of other request from mine management for grant-in-aid for purchase of ambulance Van/equipment pending with Welfare Commissioner indicating date of receipt. ii) In case this proposal has been submitted out of turn indicate reasons in detail.

Welfare Commissioner

Scheme no. 14 APPENDIX-I1 Name and address of the limestone and dolomite mine.

2 No. of workers and their families to be benefited in the proposed scheme.

3 Extent of mechanization.

4 Distance from housing colony to the nearest hospital.

5 The distance between the general hospital to the mine hospital / dispensary

6 Month-wise production for last three years.

7 Total cess paid for the last 3 years (year-wise figures).

8 Total cost of ambulance van proposed to be purchased.

9 Other relevant particulars justifying for the purchases of ambulance van.

APPENDIX – II

STAMP

Agreement between -----------------------------------------------------------------------------------

And President of India

This agreement made this--------------------------------------------------------------------

Day of ----------------------------------- one thousand nine hundred ninety ---------------------

-----------------Between--------------------------------------------------------------------------------

----------------Ltd., a limestone / dolomite mines company recognized under the companies Act. 1956 /

(1) --------------------------------------------------(2)---------------------------------------------

(3)----------------------------------------------------Partners / proprietors of-------------------

------------------------------of limestone / dolomite mines and having itsregistered

Office at --------------------------------------------------------------------------------------------

Carrying in business under the firm and style of ----------------------------------------

-------------------------at-------------------------------------------in the town of ---------

----------------------------------and having its /--------------------------------------------

-----------------------------------------------------Of the state of-----------------------------

hereinafter referred to as the applicant / the applicant which terms shall unless excluded by or repugnant to the subject or context include (its successor and permitted assign) (all partners of the said firm and their respective heirs, executors, administrators and the permitted assign of the said partners ) of the one part and the president of India (hereinafter called the “government” which terms shall unless excluded by or repugnant to the subject or context include it successors and assign) of the other part.

WHEREAS the “Application / the application” has / have applied for sanction of grant-in- aid under rule 37 of the limestone and dolomite mines labour welfare fund rules 1973 and the “Government” have sanctioned Rs --------------------------------------------------------

-------------------------------------------------(Rupees------------------------------------------------)

only as subsidy for purchases of the following equipments for improving this dispensary

at-------------------------------------------------------------------------------------------

(2)

Maintained for their limestone miners and their dependants vide letter No.------------------Of government of India ministry of labour, New Delhi

ITEMS COST 1 2 3 4

Now this indenture witness as follows:

1 The payment of the above grant-in-aid shall be subject to the following conditions.

(a) That the work or which the grant is made is duty and promptly executed and the money is actually utilized for the purpose forwhich it is granted.

(b) That the date on which the grant is calculated are in accordance with facts

(c) That any particulars which the central government may from time to time require for the proper discharge of this responsibilities are promptly supplied

(d) That all necessary facilities for inspection are accorded to persons duly authorized by the central government for the purpose of clause (A) or for checking the correctness of any particulars supplied under clause (C) or for the collection of any such particulars

(e) That proper accounts of the money granted are kept and are submitted for audit by such persons as the central government may authorized in this behalf

(f) That an additional statement of accounts together with a certificate of a registered accountant or other recognized body of auditors to the effect that the accounts are correct, is furnished by the grantee.

(g) The agreement shall remain in force until the ambulance van is declared unfit for use by the regional transport authority.

(h) The management shall send an annual certificate on of before 15th of January every year to the effect that the van is being utilized as ambulance for the welfare of the mine workers. A proper log book is being maintained until the van is declared unfit

2 The fund shall be released in one lump sum and the money shall be utilizedfor the aforesaid purpose within one month of the released of the fund as stipulated (1) above

3 In the event of violation of any condition imposed under (1) above, the applicant owner shall be liable to pay central government a sum of Rs.----

------------------------------- (Rupees ------------------------------------) By way of interest @ 14% per annum in addition to refund of the entire remaining grant-in-aid

IN WITNESS WHEREOF the parties hereto have signed this deed on the day and year first above written.

EXECUTED BY Shri--------------------------------------------------------------------

Welfare commissioner, beedi workers welfare fund / iron ore / manganese ore / chrome ore mines labour welfare fund / mica mines labour fund / limestone and dolomite mines labour welfare fund for and on behalf to the president of India in the presence of ----------------------------------------------------------------------------------------------------------------------------------

In case of companies only. COMMON DEAL FO M / S------

__________________________________________________________

Affixed under resolution of the board of directors dated ---------------------------

Affixed in the presence of Shri --------------------------------------------------------

------------------ Director and Shri ------------------------------------------------------

Secretary of the company

CHECK-LIST FOR PROPOSAL TO THE MINISTRY FOR SANCTION OF GRANT IN AID IN FAVOUR OF THE MINE MANAGEMENTS FOR PURCHASE OF AMBULANCE VAN

1. Name and address of the mine management

2 Name and location of the dispensary / hospital maintained by the mine management for the benefit of their mine workers 3 No. of mine workers / factory workers and other local people (including

family members) who are allowed treatment from hospital / dispensary

4 No. of mine workers / factory workers and other local people (including family members) treated in the dispensary during three years preceding the year in which proposal is made

5 Whether treatment charges are received on treatment of non mines, if so, proceeding the year in which proposal is made

6 Name of the items proposed to be purchased

7 Cost of the items proposed to be purchased

8 Copy of quotation to indicate the cost of items in duplicate.

9 Cess paid by the mine management in each of the year during 3 years preceding the year in which proposal is made

10 Grant-in-aid received by the mine management in each of the year during the three year preceding the year in which proposal is made (please mention scheme wise and year wise).

11 A copy of the inspection report of the dispensary / hospital maintained by the mine management for the year preceding the year in which proposal is made.

12 A copy of agenda and minutes of the S. A. C. meeting in which proposal has been recommended by S. A. C.

13 Sanction budget grant under the head “Health-grant-in-aid” during the financial

year (including provision made in R. E. also in case at the time of submission of proposal.)

14 Expenditure incurred out of the sanctioned budget grant / proposed R. E. under the “Grant-in-aid” at the time of sending the proposal.

15 Expenditure committed under the head “Health-Grant-In-Aid” as on the date of submission of this proposal (indicate item wise.)

16 Balance in hand to meet the expenditure inter-alias for the proposal being sent to the ministry.

17 Proposed manner of spending the balance provision (indicate item wise.)

18 Rules / scheme under which the proposal is covered. (1) Whether the mine management already has ambulance van (s)

(2) Were these purchased by Grant-In-Aid from L.W.O.? (3) If yes, give reason as to why the management needs another ambulance vans and why grant in aid should be given by L.W.O

19 Whether the management already has in the dispensary / hospital the equipments for which grant-in-aid is being proposed (2) were these purchased by grant-in-aid from L.W.O (3) if yes, give reasons, as to why the management further needs the equipments and why grant-in-aid should be given by labour welfare organization.

20 (1) List of other request from mine

management for grant-in-aid for purchase of ambulance van / equipments pending with welfare commissioner indicating date of receipt.

(2) In case this proposal has been submitted out of turn (indicate reason in detail

APPLICATION FOR AMBULANCE VAN

1 Name and address of the limestone and dolomite mines 2 No. of workers and their families to be benefit in the proposed scheme.

(a) Mines workers. (b) Factory workers. (c) Local people. 3 Extent of mechanization

4 Distance from housing colony to the nearest Hospitals 5 Name and location of dispensary / hospitals maintained by mines management for mines workers. 6 The distance between the state general hospital to the mine hospitals / dispensary.

7 Whether treatment charges received on the treatment of nonmines. If so amount received during last 3 years/

8 (a) whether the mine management already has ambulance van (b) Were there purchased by grant-in-aid from welfare organization. (c)If yes, give reasons for replacement.

9 Total percentage of mine workers treated during the preceding years from the total patients treated.

10 Month wise production for last 3 years. 11 Total cess paid for the last 3 years (year wise figure). 12 Total cost of ambulance van proposed to be purchased. 13 Other relevant particular justifying for the purchase of ambulance van.

Scheme no. 15APPENDIX – I

Application form for the grant of benefit under the mica / iron ore, manganese ore and chrome ore and limestone and dolomite mines fatal and serious accident benefit scheme.

******* To,

The welfare commissioner, Labour welfare organization,

Subject:- Grant of benefit under the mica / iron ore, manganese ore and chrome ore and limestone and dolomite mines fatal and serious accident benefit scheme.

******* Sir,

I beg to apply for the grant of benefit under the mica / iron ore, manganese ore and chrome ore and limestone and dolomite mines fatal and serious accident benefit scheme. The requisite particulars are given bellows:-

(a) Name of the applicant (b) Relationship with the worker (c) Address (d) Name of the worker with father‟s / husband‟s name (e) Name of the mine where employed (f) Post on which employed (g) Place where the accident took place (h) Date and time of the accident (i) Nature of accident (j) Whether the accident was fatal or it made the worker totally and permanently incapacitated? (k) No. of school going children

Sl. Name of Sex Age Name of the Class in Date Remarks No. the child institution in which Which studying Studying of admission

I solemnly affirm that:

(i) The particulars given above are true (ii) I am a widow / widowers of the deceased worker and have not re-married(iii) I am dependent on the deceased worker (iv) I am the father / month / son / daughter / unmarried or widowed sister/ brother of the deceased worker (v) I am the guardian of the deceased worker (vi) No girl mentioned in (k) above is married

*Strike off whichever is not applicable

Signature of L. T. I. of the applicant.

Certificate to be signed by the head of the educational institution.

Certified that the particulars given in col. (k) are correct. The student are continuing in their classes

Date Place Signature of the headmaster Seal

Certificate to be signed by the Mukhia of the gram panchyat or the manager or agent of the mine concerned.

_________

Certified that the particulars given by the applicant are true and correct

Signature of the Mukhia of panchayat/ Manager or agent of the mine.

Name Address Designation Name of the mine or village

Seal of the MukhiaManager or agent Date.

(iv)Certificate of the superintendent of any of the hospitals of the mica / iron ore, manganese ore and chrome ore and limestone and dolomite mines labour welfare fund or the medical officer of the mine hospital. ----------

Certified that the worker Shri / Smt. _______________________________ Employed in ____________________(Mine) as_______________________ Was involved in the accident__________________at___________________ (Mine) on ___________________at (time) ___________________________ and has died / has been permanently and totally incapacitated.

Place Date Signature of medical officer Seal

Scheme no. 16FORM OF APPLICATION

1. Name in full of the worker :2. The Name and address in full of the Mine/Beedi establishment where the

worker is employed. 3. The date of his employment and total Continuous service.4. Designation or the nature of his employment 5. His monthly salary/wages(excluding bonus) 6. The Hospital where admission is sought. 7. Whether he was admitted previously in the

reserved bad under this scheme. If so give date and the period of his stay and the name of the hospital.

Signature Name

Dated:

ATTESTATION OF THE MANAGER/OWNER

It is certified that Shri/Smt.______________________________is employed in this Mine/Beedi establishment as ______________________continuously for ______________years__________months and to be best of my knowledge and information the particulars given above by him/her are correct.

Signature

Date Seal Manager/Owner Name & Address of the establishment.

CERTIFICATE FROM THE MEDICAL OFFICER

Shri___________________________employed____________________in establishment and whose signature/thumb impression is given hereunder, was examined by me on ______________________and was found to be suffering from _________.According to my opinion his admission in one of the reserved beds in this hospital for Mine/Beedi workers is/is not absolutely necessary for ____________________days(approximately).

Date Seal Signature Name

FORM OF REGISTER TO BE MAINTAINED IN HOSPITALSWHERE BEDS ARE RESERVED FOR MINE/BEEDI WORKERS

____________________________________________________________________ S. Name Nature of Name of Date of Nature Duration CompleteDate of Signature Remarks No. of the employ- the estab- admission of sick of reten- or partial discharge of the Dr. Workermentlishmentnesstionrecovery

This agreement made on the______________day of _________198 between the medical officer in charge__________Hospitalat__________here in after called the hospital (which expression where the context so admits shall include successors or assigners on the one part and the president of India, acting in the premises through the welfare Commissioner for Labour Welfare Fund here in after called “the Central Government(which expression shall, where the context so admits, include his successors and assigners) on the other party whereby it is agreed as follows:-

(1) This agreement is initially for a period of one year with effect from _________.This agreement may be renewed for a further period upon such terms and conditions as may be mutually agreed upon.

(2) Agrees and undertakes to reserve ______________bed (_________) beds in the hospitalat___________here in after called the hospital for admission of patients requiring hospital treatment for Mine/Beedi Workers at a cost of Rs.______________per bed per year (here in after called the reservation charges).The reservation charges at the rate shall be payable by the Central Government for the period such beds are reserved.

(3) The Welfare Commissioner, Labour Welfare Fund will cause to be paid from Welfare Fund reservation charges in the beginning of every three months with effect from the date of this agreement.

(4) The occupants of such reserved beds will receive full facilities of the hospital, staff, Of the equipment, medicines, nursing, food and other amenities of the hospital such as ambulance etc. and will receive the same treatment in all ways as other patients in the hospital.

(5) Reservation charges of Rs. ___________(Rupees______________________) will include all the expenditure incurred routine and special medicines, injections, etc. required as well as charges for X-Ray operations.

(6) Admission to the reserved beds will be arranged through Welfare Administrator or any other officer authorized by the Welfare Commissioner of the Labour Welfare Fund in consultation with Medical Officer in charge of the hospital at

_________________.

(7) Admission of the patient shall not be refused by the Medical officer-in-charge of the hospitalat_____________if the number of patients among the Mine/Beedi Workers is less than the number of beds reserved, nor such admission to Mine/Beedi workers refused, even if the number of such patients exceed______________in the beds are otherwise vacant in the Hospital.

(8) Inspection of the reserved beds in the hospital may be made by the Welfare Commissioner Labour Welfare Fund or any other person authorized by him with or without notice to Medical officer in charge of the hospital.

(9)Progress report on every patient admitted to the reserved beds will be forwarded by the Medical officer in charges of the hospital to the Welfare Commissioner, Labour Welfare Fund every month by the 10th of the next month and cases of death of any persons admitted under this scheme will be reported within 24 hours of the occurrence.

Scheme no 1

FORM OF HOUSING

FORM OF APPLICATION FOR GRANT OF SUBSIDY UNDER REVISED INTEGRATED HOUSING SCHEME (RIHS) – 2005, FOR BEEDI WORKERS

ETC.

TO,

THE DISTRICT COLLECTOR /DEPUTY COMMISSIONER, DISTRICT MAGISTRATE ________________________ (Name of the District)

Sir,

PART-I

1. (a) Name of Beedi/Mine Workers with his/her Father‟s/Husband/s Name with complete Present

Postal Address; and (b)Name & Address of Establishment, if employed

2. Date of Birth & Age on the date of application :-

3. Date of appointment as per „B‟ register:-\

4. Monthly average income of the family :-

(Should NOT exceed Rs. 6500/- in case of Beedi Workers &Rs. 10,000/- for Mine workers)

5. Details of Provident Fund A/c No. or Identify Card No.

(Enclose a Xerox copy):-

6. Details you own nay house in your name or in the name

Of your spouse of any of your dependent sons/daughters

If so, give details:-

7. Complete details of the Plot etc. where the house is proposed to be constructed :-

(i) Is the plot/site in your possession or jointly/severally with other members of his/her family, so on what term:-

Photographs of beneficiary with his/her spouse and signature/thumb impression on their photographs

A. Details of settlement deed, if any :-

B. Area of Plot :-

C. Site Survey No. :-

D. Name of Village/Town/City:-

E.Post Office with Pin Code :-

F. Taluka/Mandal :-

G.Name of District/State :-

8. A) Details, if any house has been provided to the applicant/ by spouse the State/Central Government under any other housing scheme.

B) Have you or your spouse has earlier availed Any subsidy under BYOHS/GHS/EWS Housing Scheme:-

9. Is the title of the plot/site clear and free from all encumbrances? (Enclose relevant documents concerned revenue authorities) :-

10. Enclose estimate of the cost of construction with a layout plan approved by the

concerned authorities :

11. Details of Employees contribution of Rs. 5,000/- Amount Rs.

a) By Cash/Cheque/DD

b) Cheque/DD No. & Date

c) Name of Bank

12. If the plot/site is allotted by the State Government or local bodies, (Attach attested copies of relevant documents from the concerned authorities

13. Do you agree to the execution of the agreement prescribed under the scheme?

14.a) Do you agree to produce a surety as required under the scheme?

b) If yes, Name and Occupation of the surely with full postal address:- (Surety should possess property valuing not less than Rs. 45,000/-. If it is not possible to arrange a surety the applicant shall mortgage that land on which he/she proposes to construct a house in the prescribed form).

15. Does the applicant belong to SC/ST/OBC? If so, attach a copy of the Certificate from the competent authority.

I certify that the particulars given in this application are true to the best of my knowledge and belief.

Place:- Signature/Thumb impression of the Beedi/Mine Worker

Date:-

Verified the above particulars and found correct. He/she fulfills the eligibility requirements of obtaining the subsidy for construction of a house under the Revised Integrated Housing Scheme, 2005 of Beedi Workers etc. (BYOHS/GHS) implemented with the subsidy of Government of India, Ministry of Labour & Employment. Hence his/her name has been included in the list of beneficiaries.

Place:- Date: - SIGNATURE OF THE DISTRICT COLLECTOR/ DISTRICT MAGISTRATE/DEPUTY COMMISSIONER*

(With Name & Officer Seal)

* NOTE :- The certificate on the Application Form is to be signed by the District Collector / Dist. Magistrate/Deputy Commissioner of the concerned, himself. Signature of any other Officer nominated by the DC/Dy. Comm. / DM or otherwise, would NOT BE ACCEPTED.

PART-II

CERTIFICATE OF THE MANAGEMENT OF BEEDI/MINE ESTABLISHMENT

I am certifying that applicant is an employee of this Beedi/Mine Unit/Establishment from ______________ (Date of appointment) as the B. Register _________________ No. _______________ and still working as Beedi worker to the best of my knowledge and belief. I recommend that the application may be considered favorably.

Place:- Signature of the Manager/Owner/Agent/Contractor (with Seal)

Date:-

Note: - In case the Contractor/Agent signs the certificate, the Manager/Owner of the Beedi/Mine Establishment has to counter sign. Otherwise, the above certificate will not be treated as valid.

CERTIFICATE OF THE VILLAGE OFFICER / SUB REGISTRAR(REVENUE AUTHORITY)

It is certified that after investigation from the records of the Sub-Registrar ___________________ and relevant Revenue and / Court records and form the information gathered from the sworn declaration made by Shri/Smt. _________________ and that ______________________ Survey No. ________________________ / Vacant Plot No. ___________________ Measuring ___________________ Sq.Yards/Meters at in the limit of ________________________________ is the absolute property of Shri/Smt. ______________________________________ Son/Wife/Daughter of Shri/Smt. ______________________________________ and * joint family property* / not a joint family properly. The said property is free from all encumbrances & attachments and Shri/Smt. ______________________________________ has clear and marketable title to the property. (* Strike off whichever is not applicable).

Place: Signature: Date: Designation:

Seal

Note:-

1. Certificate should be obtained from the concerned revenue authorities and from the Gram Panchayats.

2. In case where the worker possesses plot/site jointly/severally with other members of the family, there should be settlement deed in support of no objection for construction of house.

LIST (IN DUPLICATE) FOR VERIFICATION & INSPECTION OF

APPLICATIONS/APPLICANTS UNDER THE “BUILD YOUR OWN HOUSE

SCHEME” (BYOHS) FOR THE REVISED INTEGRATED HOUSING SCHEME-2005

(RIHS-2005) FOR THE BEEDI/MINE WORKERS.

NAME OF THE FUND ___________________________________________ SL.NO. OF APPLICATION __________________________________________

1. Name of the applicant : Shri/Smt./Miss

2.Father/Husband‟s name :

3. Applicant‟s residential address :

4. Whether working in Management/Gharkhatta :

5. Name and Address of the Management/Contract :

6. a) Whether he/she or spouse owning a house? : YES/NO b) If yes, details of benefits availed under any Scheme:

7. Identity Card and/or P.F. A/c No. :

8. Monthly family income of the applicant :

9. Whether the application in the prescribed form? : YES/NO

10. Whether all the Columns in the application form filled : YES/NO

11. Has the Certificate countersigned by the Management or Contractor or Agent Filled-in and signed”? 12. Does the applicant belong to GEN CAT./SC/ST/OBC :

13. Status of the land (if owned individually, jointly or ancestral or allotted by the State Govt.

14. If the land owned jointed by other members of the family, letters of No Objection by other members of the family have been enclosed: YES/NO

15. Whether the site plan, building plan and specification with estimates Enclosed i.e. the cost of construction : YES/NO

16. Has he/she filled the sale/transfer/settlement deed : YES/NO

17. It the area NOT less than 60 Sq. Yards. : YES/NO

18. Whether he/she put in a service of 1 (one) year : YES/NO

19. Whether he/she sanctioned any subsidy for the house previously: YES/NO

20. Cost of proposed construction of house (should not exceed Rs. 1 Lakh):

21. Has the applicant deposited Rs. 5,000/- along with the application : YES/NO (Cash/demand draft No., date, amount etc. and other details)

22. Has the Non-encumbrance certificate (NEC) been enclosed along: YES/NO with the details of boundaries of the proposed site and transaction deed:

23. Life span of the house(s)

It is certified that the details given in the check list have been got verified and found to be

order. He has not availed any subsidy under any Scheme, earlier. The applicant or his/her spouse

does not own a house in his/her name. The applicant is eligible to avail benefits of housing

subsidy under the RIHS, 2005.

Place:-

Date: -SIGNATURE OF THE DISTRICT COLLECTOR/ DISTRICT MAGISTRATE/DEPUTY COMMISSIONER*

DETAILS OF THE INSPECTION AUTHORITY

No. ____________________ Date ____________

FIRST CERTIFICATE OF INSPECTION (FIRST PHASE)

With reference to the letter No. _____________ dated _______________ from the

______________________________________ (details of the concerned DC/Dy. Comm./DM) in

respect of administrative approval granted by the Director General Labour Welfare, Ministry of

Labour & Employment, Government of India, New Delhi vide its sanction letter No.

_____________ dated ________________ for ____________ houses for Beedi/Mine Workers, I

am to inform that the houses constructed by the following Beedi/Mine Workers under the

Revised Integrated Housing Scheme, 2005 for Beedi workers etc., have been inspected by me

from ___________ to ______________ (Specify the dates of inspection) and found that the

houses are being constructed in accordance with the terms & conditions of the Scheme and

specifications mentioned in approved lay-out plan and the construction of these houses have

reached up to roof level.

SI.NOName of Father/Spouse’s Name of Worker Address

2. It is, therefore, recommended that these beneficiaries have become eligible for the

secondinstallment of subsidy @ Rs. 20,000/- per tenement. The second installment in respect of

the each of the above ______ (No. of houses) may kindly released.

Date: Place: (Name & Designation of the inspecting Authority)

(With Office Seal)

DETAILS OF THE INSPECTION AUTHORITY

No. ____________________ Date ____________

SECOND CERTIFICATE OF INSPECTION (FIRST PHASE)

With reference to the letter No. _____________ dated _______________ from the

______________________________________ (details of the concerned DC/Dy. Comm./DM) in

respect of administrative approval granted by the Director General Labour Welfare, Ministry of

Labour & Employment, Government of India, New Delhi vide its sanction letter No.

_____________ dated ________________ for ____________ houses for Beedi/Mine Workers, I

am to inform that the houses constructed by the following Beedi/Mine Workers under the

Revised Integrated Housing Scheme, 2005 for Beedi workers etc., have been inspected by me

from ___________ to ______________ (Specify the dates of inspection) and found that the

constructed of under mentioned houses has been COMPLETED as pr the plan & specifications

of the Scheme. These houses are durable to sustain a life span of minimum 20 years, in

accordance with the terms & conditions of the Scheme.

SI.NOName of Father/Spouse’s Name of Worker Address

2. These houses have been complete in all respect and Central Subsidy of Rs. 40,000/- has

been fully released to the beneficiaries in respect of above _______ (No. of houses) and has been

utilized in accordance with the terms and conditions of the Scheme.

Date: Place: (Name & Designation of the inspecting Authority)

(With Office Seal)

REVISED INTEGRATED HOUSING SCHEME-2005 FOR BEEDI WORKERS ETC.

(Utilization Certificate in Form GFR 19-A)

NAME OF THE DISTRICT _________________________ STATE ___________

a) Unspent Balance from Previous Year : Rs. _________ Lakhs

b) Grants received during the year : Rs. ____________

Certificate that a sum of Rs. ____________ Lakhs was received by the D.C./D.M./Dy.

Comm. ____________ (Name of the District) as Grants in Aid during the Year

____________ as per details given in the margin from the Centre and the State Govt. As

housing Subsidy, amounting to Rs. ____________ Lakhs, Further a sum of Rs.

____________ Lakhs being inspect balance was allowed to be brought forward for

utilization during the current year ____________. The receipt on account of the

Workers‟ Contribution during the current year ____________ was Rs. ____________

Lakhs.

c) Misc., receipts of the Authority :

d) Receipts on account of Worker‟s Contributions :

e) Interest receipts :

Total Funds Available (a+b+c+d) :

Letter No. Date Central Govt. : State Govt. Total

It is also certified that out of the above mentioned total funds, together with the receipt of

worker‟s contribution, they total funds of Rs. ___________ Lakhs available with the

____________ (Name of the District & State), a sum of Rs. ____________ Lakhs has been

utilized by ____________ (Name of the Agency) during the financial year ____________ for the

purpose for which it was sanctioned. It is further certified that the unspent balance of

Rs. ____________ Lakhs remaining at the end of the financial year would be utilized for the purpose next year.

3. Certified that I have satisfied my self that the conditions on which Grant-in-Aid was sanctioned have been duly

fulfilled/are being fulfilled and that I have exercised the following checks to see that the money has been actually

utilized for the purpose for which it was sanctioned.

i) ii) SIGNATURE OF DC/DM/Dy. Comm. Of the Concerned District Date : (with Name and Officer Seal)

Scheme no. type 2Questionnaire to ensure the Safety of the proposed

Houses under the Housing Scheme to be answered by the Applicant Mine Management.

1. If the Site falls over a Limestone/Dolomite bearing land, whether any workingexist?

2. If virgin, whether management have any intention for working the scheme during the life of the low cost houses (type II Houses)

3. If developed whether:-

a. The workings are stable :

b. The workings are affected by fire? :

c. The workings are accessible by fire? :

d. The management intends to extract :

e. The plan showing the workings and site is certified to be correct?

f. The depth of cover is adequate? :

g. The strata is competent for its stability:

4. If the proposed site is over a caved out area :a. When was depillaring completed? :

b. Whether the ground is considered settled: If so how the management has ensured if c. Whether any under ground sport level have Been maintained? d. In case of further extraction of underlying: Seams, proposal may not be accepted e. Whether the death of cover is adequate: For stability of the houses?

f. Whether management propose to extract: Underlying seams in conjunction with Showing which will maintain the strata stable?

5. Whether an undertaking to the effect that in Case the houses are damaged because of mining Activity(s), the management will pay adequate Compensation to Central Govt. is attached.

6. Whether construction will be done 400 meter :Away of the working place so that damage by Blasting is eliminated.

Signature:

Name:

Designation:

FORM OF RECREATION

Scheme no . 2

PROVIDED ALWAYS AND IT IS HEREBY AGREED THAT

1 In the event of violation of any of the afore mentioned conditions by the second party, the second party, shall be liableto pay to the first party the amount of Rs. ___________ (together with interest at the government rates for the time being in force) on demand without a demur.

2 This bond is given for the performance of an act in which thepublic are interested.

IN WITNESS here of the common seal of the company hashereinto been affixed the day and year first above written. Signed, sealed and delivered by Shri.

Welfare and cess commissioner, limestone and dolomite mineslabour welfare fund, for and on behalf of the president of India in the presence of 1 2 The common seal of the above named has hereinto been affixed by the direction and in the presence of

1 2

AGREEMENT

This agreement is made this the ______________ day of one thousand nine hundred and ________________between the president of India hereinafter referred to as the first party which expression shall unless excluded by or repugnant to the subject or context including his successors and assigns of the one part and having their registered office at ____________ in the town of ____________________ hereinafter referred to as the second party which expression shall unless excluded by or repugnant to the subject or context be deemed to include their successors and assigns of the other part.

WHEREAS a sum of Rs. ____________ (rupees ________________) only has been granted by the first party from the limestone and dolomite mines labour welfare fund under section 5 (2) (c) of the limestone and dolomite mines labour welfare fund act, 1972 to the second party for setting up of a sports ground at

AND WHEREAS the second party has agreed to accept the said grant.

NOW THEREFORE THIS AGREEMENT WITNESSETH and the parties hereto hereby agree as follows:-

1 That all the right in respect of the land on which the sports

ground is to be set up have been acquired by the mine owner‟sand shall continue to rest with them for a period of not less than ten years. 2 That as the said sports ground shall be set up on the piece of land marked “A” in the enclosed plan attached hereto as annexure I and according to the specifications as given in annexure II :

FORM OF APPLICATION FOR GRANT-IN-AID FROM THE LIMESTONE AND

DOLOMITE MINES LABOUR WELFARE FUND TOWARDS PROVISION OF SPORTS

GROUND IN THE LIMESTONE AND DOLOMITE MINING AREA.

-------------1 Name of the mine with postal address

Thane District State

2 Name of owner with address

3 No. of workers employed

Male Female

4 Total population in the mine

5 No. of houses provided Single Double .roomedroomed .tenementstenements

(a) by the management (b) under the housing scheme of the fund (c) under any other scheme

6 Is the site proposed for the sports ground centrally situated ? (Site plan showing locations are to be given)

7 Estimates of cost for preparing the sport ground. (Detailed works estimates to be attached with plans wherever necessary).

8 The amount of grant-in-aid applied for (Should not exceed Rs. 3,000 /-)

9 Is the management prepared to acceptthe terms and conditions laid down in the enclosed form of agreement and to execute such an agreement.

Signature of mine owner’s

Scheme no. 4

BOND

BOND FOR PURCHASE OF A DISH ANTENNA FOR THE RECREATION OF THE MINE WORKERS

This bond is made this the………………day of one thousand nine hundred and ninety…………between the………………………(Name of mine management its registered office at…………………..(hereinafter referred to as the mine management which expression shall unless excluded or by repugnant to the subject or context to be deemed to be included their successors in interest and assigns) of one part and president of India (hereinafter referred to as “Government” which expressions assigns) of the other part.

WHEREAS pursuant to the request of the mine managements the government has agreed to provide a caloured / black and white TV set coasting Rs…………/- (rupees….......only) to the said mine management / society as per the provisions of prototyped scheme for supply of TV sets to mine managements / beedi co-operative society for recreation of their mines / beedi workers under iron ore, manganese ore and chrome ore mine labour welfare act 1976 limestone and dolomite mines labour welfare fund act 1972, mica mines labour welfare fund act 1946, beedi workers welfare fund act 1976. Up on furnishing a bond on the terms and conditions appearing hereafter.

And whereas the said mine management / society has agreed to say TV set.

NOW, THEREFORE THIS BOND WITNESS AND THE PARTIES HERETO, hereby agree as follows

1 that the cost of TV set including all accessories shall not axed Rs.10000/- (Rupees ten thousand only)in case of colour TV and Rs 4000/-(Rupees four thousand only) 2 That the TV set shall be purchased iron a government manufacturer through a reputed regular dealer and produce the cash memo to that effect or reimbursement of the admissible expenditure by the welfare commissioner------------------------region 3 That the said mine management /society shall execute an agreement in the prescribed from of agreement

4 That the incidental expenses incurred in connection with operation of the TV set will have to borne by the said mine management / society 5 That suitable accommodation for installation of TV set shall be provided by the said mine management / society 6 That in case the TV set remain un-utilized for a reasonable period and / or utilized other that the purpose for which it is provided the welfare commissioner shall have powers to withdraw the TV set so provided to the mine management / society 7 That in case the like of life TV set is out lived its utility, the set mine management / society shall have no right to dispose of the TV set in any manner they shall have to return the TV set to the welfare commissioner, region and obtain receipt in token there of. 8 That the expenses incurred on repair up keep the TV set in good working condition shall be borne by the mine management / society. 9 That the TV set shall be installed at such a central place of mine / beedi workers population which are within their easy reach and can witness the TV programmed at large. 10 That the TV set shall be maintained in good condition and will be used only for benefit of mine / beedi workers 11 That any particulars, which the government or any person authorized by it, may from time to time require for the proper discharge of responsibility shall be duty and promptly supplied 12 That or necessary facilities shall be afforded for inspection by the officers of government or any person authorized by it.

13 That the TV set shall not be transferred or utilized by any other than said mine / management / society for the purpose it is meant for

In the event of violation of any of the aforesaid conditions by the said mine

management / society of which the government shall be the sole judge, the said mine management / society shall be liable to pay the government amount Rs. ------------together with the interest at the government rates for the time being in force on demand without a demur, for crediting the some to iron / chrome / manganese ore mice mines / limestone and dolomite mines / beedi workers labour welfare fund.

The bond is given for the performance of an act in which the public are interested.

In witness where of the mine management / society have caused to execute / authorized their seal through their unauthorized representatives on the day and year first above written.

Sealed, signed and delivered this the ------------------day of the one thousand nine hundred and ------------------in the presence of.

WITNESS

1 Name 2 Name SignatureFather‟s name Father‟s name Occupation Occupation Designation ResidenceResidenceSeal

AGREEMENTAGREEMENT FOR PURCHASE OF A COLOURED / BLACK & WHITE T.V. SET FOR THE RECREATION OF THE MINE

WORKERS

This agreement made this---------------day of----------------between the president of India (herewith referred to as “the government”) of the one part and the------------ (name of the mines management / beedi co-operative society) (herein after referred to as the “employer”) of the other part.

WHEREAS the iron ore. Manganese ore and chrome ore mines labour welfare fund advisory committee / limestone and dolomite mines labour welfare fund advisory committee / mica mines labour welfare committee / beedi workers welfare fund advisory committee for (state) has recommended the proposal for supply of coloured / black and white TV set for the recreation of iron or manganese ore / chrome ore / limestone and dolomite / mica mine workers / beedi workers employed by the (employer) in accordance with the provisions contained in iron ore mines and manganese ore mines / chrome mines labour welfare fund act, 1976 / limestone and dolomite mines labour welfare fund act, 1972 / mica mine labour welfare fund act, 1946 / beedi workers welfare fund act, 1976.

AND WHEREAS in pursuance to the set recommendation, the government has agreed to accept the proposal for the supply of coloured / black and white TV set including all accessories, at cost not exceeding Rs.---------------to the employer out of the iron ore / manganese ore chrome ore labour welfare fund / limestone dolomite mines labour welfare fund and the employer has agreed to accept the same on the term and conditions appearing hereinafter.

NOW THIS INDENTURE WITNESSES THAT IN consideration the aforesaid and in consideration of the terms and conditions to be observed by the employer, the government has supplied one coloured / black and white TV set chassis-------------no.--------------------- Make-----------------model---------------etc. (hereinafter referred to as the said TV set) to the mines management / beedi co-operative society and incurred Rs.-------------towards the cost of the said TV set.

2 The employer hereby undertakes that:-

(a) The said TV set shall be used exclusively for the recreation of the mine / beedi

workers but excluding the supervisory staff of the management / beedi co-operative society. (b) On the body of the said TV set the words “supplied by the labour welfare organization “ shall be printed in English or local language commonly understood by the population of the region (c)The said TV set shall not be disposed of encumbered, or utilized for the propose other than for the recreation of the mine / beedi workers. (d) The employer shall at its expenses safeguard the said TV set, maintain it in good working order and shall bear full / cost charges and expenditure on this proper

functioning un keep including repairs.

3 Any particulars, which the executive officer of the labour welfare organization may require from time to time for proper discharge of their responsibility with regard to the satisfactory and maintenance and proper use of the said TV set shall be duty and promptly supplied by the employer and for the verification, for which necessary facility for inspection shall be afforded. 4 It is further declared that in the event of violation of any of the above conditions the employers shall be liable the pay to the central government for crediting to iron ore manganese ore and chrome ore limestone and dolomite mica mines labour welfare fundbeedi workers welfare fund the entire amount incurred on the purchase on the said TV set along with interest on the cost of the TV as fixed by the central governmentIN WITNESS HEREOF THE PARTIES caused their hands to set through their respective authorized representatives on the day and year first above return.

Place: Date: (signature)

In the presence of witnesses:-

(i)

(ii)

FORM OF THE APPLICATION FOR PROVIDING SUBSIDY TO MANAGEMENT FOR PURCHASE OF DISH ANTENNA

(To be submitted in duplicate)

--------------------------------------

1 Name of the mine management with full postal address 2 Total no. of workers employed in the mine 3 No. of houses provided to the workers 4 Total amount of cess paid for last 3 years 5 Location of the colony with the site 6 Is the place not covered by the existing TV network, name of the nearest TV relay station and distance 7 Whether the management agrees to provide suitable facilities for installation of dish antenna 8 Place of installation of dish antenna (please mark in the site plan with place where antenna is to be installed) 9 Cost of this antenna and its capacity 10 Whether management is willing to incur the expense in connection with installation of dish antenna 11 Whether the management is willing incur the expense in connection with installation of dish antenna 12 Any other information relevant to the proposal

Date: Signature of the mine management with seal

Place:

Documents

labour.gov.in. .docx · Web viewhas in the dispensary / hospital the equipments for which grant-in-aid is being proposed (2) were these purchased by grant-in-aid from L.W.O (3) if