APPLICATION FOR THE GRANT OF
1 (a) Name (in BLOCK LETTERS)
(b) Designation, Department and office
( c) Basic pay
Scale of pay
Net salary received
Date of Birth
Whether services are regularized or not?
If so, total period service rendered.
Total no. of living children
S.No. Names of the children Age Class in which studying Academic year
Name of the institution where the child/
children are studying
I solemnly declare that the information furnished by me in reply to the various items
indicated above is true to the best of my knowledge and belief.
I certify that
My wife/husband is not a Government servant.
Neither I nor my wife/husband who is Government servant has applied
Signature of the
Place of work
No advance is pending recovery.
Sign.of Incharge of Accounts wing