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Get ESIC-72 A

ESIC- 72 A Employees State Insuarance Corporation To The Manager ESIC Local Office Dear Sir My identity Card / Family Card inner slip has been lost / defaced I have therefore to request for a duplicate identity card / Duplicate family identity card. I herewith deposit a sum of Re. 1/- only being the fee for the duplicate identity card / duplicate Family identity card. As defaced identity card / Family identity card was issued more than 5 years ago. The duplicate identity card / duplicate Family identity card may be issued to me free of charge. The particulars of the present members of my family are furnished below. S*No Name Date of birth Relationship with issued person Whether residing with him / her or not I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief* I also under stand that in case any of the particulars in my declaration is found to be wrong I shall be liable to prosecution under Section 84 of the ESI Act 1948. I further declare that the particulars furnished by me tally with those which I have already furnished earlier from time to time. Yours truly Attested Signature/thumb impression Signature of the Employer with seal Full Name. Ins* No To be completed by the Local office Identification marks if not given in benefit file / LedgerSheet. Received Re. 1/- only Rupees one Only vide cash receipt No*. Book No* Fee of Re. 1/- has not been received from the insuared person as replacement to be done free of cost. I herewith deposit a sum of Re. 1/- only being the fee for the duplicate identity card / duplicate Family identity card. As defaced identity card / Family identity card was issued more than 5 years ago. The duplicate identity card / duplicate Family identity card may be issued to me free of charge. As defaced identity card / Family identity card was issued more than 5 years ago. The duplicate identity card / duplicate Family identity card may be issued to me free of charge. The particulars of the present members of my family are furnished below. S*No Name Date of birth Relationship with issued person Whether residing with him / her or not I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief* I also under stand that in case any of the particulars in my declaration is found to be wrong I shall be liable to prosecution under Section 84 of the ESI Act 1948. The particulars of the present members of my family are furnished below. S*No Name Date of birth Relationship with issued person Whether residing with him / her or not I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief* I also under stand that in case any of the particulars in my declaration is found to be wrong I shall be liable to prosecution under Section 84 of the ESI Act 1948. I further declare that the particulars furnished by me tally with those which I have already furnished earlier from time to time. .

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