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
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 Name of the mine Date of Nature of Duration of retention or partial recovery Date of 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. e.
Sealed, signed and delivered this the ------------------day of the one thousand nine hundred and ------------------in the presence of. WITNESS 1 Name 2 Name Signature Father‟s name Father‟s name Occupation Occupation Designation ResidenceResidence Seal AGREEMENT AGREEMENT 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.