Industrial Decesesed

Application for J&A Bharat HSE Foundation Industrial Accident Victim Family Support Grant

Name of the candidate *

Email *

Phone

Communication Address *

Relation to victim of Industrial accident deceased person? *

Date of industrial accident? *

Name of the deceased person? *

Industrial accident occurred at which Company, address ? Provide supporting documentation of industrial accident. *

Name of the supervisor with designation, E-Mail ID, Phone no. *

Details Dependents of the deceased person? *

Current occupation of dependents of deceased person? *

Income source of dependents of deceased person? *

Annual income of dependents of deceased personnel ? *

Total amount of fees required for the education of dependent children ? *

Did you get any other charity foundation support? If yes, how much amount was sanctioned? *

Support amount requested from J&A Bharat HSE Foundation? *

Justification for requesting/applying for the additional grant providing with valid supportive reasons *

References of individual personnel with details of Name, address, e-mail, phone nos etc for more details *

Provide any other relevant information? *