The application referred to in sub-sectilon
(2) of section 10 of the Act shall be made in From 1, to the District Administration.
FORM-1 (See rule 12) (Application form for registration of unorganized worker)
1. Name of the unorganized worker
2. Name of Father/Husband
3. SC/ST/OBC/Gen.
(Strike off whichever is not applicable) :
4. Age (in complected years) ..................................... Years Date of Birth : Day ......... Month...Year
5. (i) Present Address : House No .....
: Mohalla;
: Village/City:
Tehsil District:
(ii) Permanent Addres : House No.
: Mohalla;
: Village/City:
Tehsil District :
6. Mobile/phone No. (if available) :
173(6) राज�थान राज-प�, माच� 3, 2011 भाग 4(ग)
7. Details of family members (Family means father, Mother , Wife/ Husband, Son & Daughter) S.No. Name of member Age Relation with member Monthly Income(in Rs.)
8. Name of occupation /work of worker :
9. Type of employment (Strike off whichever is not applicable : 1. Self employed
2. Home based
3. Wage employment
10. Monthly income of worker (in Rs.) : Rs.
11. Agrichure land holding owned (in hectare): ........ hectare
12. Whether BPL Card Holder (Yes/No) : Yes/No (Strike off whichever is not applicable) DECLARATION I ......................... son/ daughter/ wife of ........... hereby solemnly declare that I am an unorganized worker and above mentioned information given by me is correct and true.
Thumb impression/ Signature of Worker [No. F. 13(23) Sharma/Vidhi/2009] By Order of the Governor, अंजना द���त, Addl. Labour Commissioner & Ex. Officio, Deputy Secretary to the Government.
Government Central Press, Jaipur.