4. Payandscaleofpay
(a) DateofBirth
5. Date ofcommencementofcontinuous
service underGovernment
Place proposed to be visi
t
Purpose ofvisit
8. I
fitjsforseeking employment,whether
a decl
aration to the effectthathe will
eitherresignthisjoborwilltake prior
permission abroad has been attached
9. Exped ed peri
od ofabsence from duty
PR O FO R M A REPO RT
(Tobefilled fn by theHeadofOff/ce)
W hetherany discipl
inal proceedings
are pending orcontemplated against
in indi
vidual
Certi
fiedthattheinformationgivenaboveandthatgiven bytheapplicantSl.No.1to 15areverisedandfoundcorrect.
His application is recommended.
Signature:
Name:
Station:
Date:
No.274/70Tin.dated,24-9-1970& G.0.(P)No.65/76/Fin.dated,25-2-1976.
Ido hereby declarethat1haveno bonded obligation to sel'
vetheD epartm ent
.
I dp hereby declare that l have not taken any leave for the sam e purpose
previously.
Signature
CountersignatureoftheHead ofOftk e
A N N EX U R E B
AlICentralG overnm entem ployees,State G overnm entem ployees,Em ployees of
Statutory Bodies and Public SectorUndeA kings and theirdependentfam ily
m em bers are required to produce an Identity Cedificate
(Strikeoutprotionnotapplicable)
(To begivenin Duplicateon OriginalStationary)
()fi:11,tthr)lrltlrll Ittrl1)plxhrltt,r'l4)1()54th(,()fttll
-ti(()fflce11(b(1rtliii;)............-......................................................
Ii1/18rtj18(1()r)llrlCl()r!tflhrthilh/rl(,rllL)thrti;)()f1581ri/t;rtlt....................-..-.,.....................................................
andhis/heridentityiscertified.ThisMinistry/Depadment/Organisationhasnoobjectiontohis/her
acquiring IndianPasspod.The undersigned isdulyauthorisedtosi
gnthisIdentityCerti
ficate.Ihave read
Applicant's
photo to be
adested by
certifying
authority
A N N EXU RE C
Signature& Seal.
The Head ofOffice
(i
n acknowledgementofthe
receiptofthesai
di
ntimation)