; the sub regional office of employees state insurance corporation
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the sub regional office of employees state insurance corporation

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									         EMPLOYEES’ STATE INSURANCE CORPORATION
                                       SUB REGIONAL OFFICE
          1897, TRICHY ROAD, RAMANATHAPURAM, COIMBATORE – 641 045.
         Ph: 0422 - 2314430, 2316430 Fax: 0422 – 2315970 Email: jtdir@sancharnet.in   Web: www.esicoimbatore.org


                 FORM OF REGISTRATION FOR E.S.I. WORKSHOP

             Place, Venue and                   Place, Venue and                  Place, Venue and
                    Date                              Date                               Date                      Serial No:
             COIMBATORE                            TIRUPPUR                           ERODE

            CODISSIA HALL                        SIHMA HALL                           Oxford Hotel,
              Husur Road,                         TIRUPPUR.                              Erode.
             Coimbatore-18.


                  05.03.2008                      03.03.2008                           28.02.2008
                                                Tick your venue



                    PERSONALS DETAILS OF THE PARTICIPANT

Name (in Capital)                                      :

Address (in Capital)                                   :
                                                           …………….……………………………..

Telephone No                                           ………………………………………………

E_mail                                           : ……………………………………………….

           REPRESENTING                     FACTORY / ESTABLISHMENT (if any)

Name of unit / factory /
establishment……………………………………………………...

Address of the unit / factory
/establishment……………………………………………….

ESI Code No.
………………………………………………………………………………..

Telephone No ……………………… e_mail …………………………………………….

Designation of participant ……………………………………………………………………

                                           FEE PARTICULARS

Amount by Cheque                       : …………………………………………
D.D                                    : …………………………………………
Date                                   : …………………………………………
Bank                                   : …………………………………………

                                                                                       Signature of Participants

								
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