FORM - I Andaman & Nicobar Administration Housing and Estate Department Application for allotment of Govt. accommodation under General Pool [ Please fill the application form in BLOCK letters] 1. Name of employee : S/o or W/o 2. Date of birth Date of arrival in station Priority date* Date of Initial appointment Date of confirmation in service Date of retirement 3. Status of employment( Regular/Temporary) : Regular Temp. 4. State whether you are eligible for rent free accommodation:: Yes/ No State whether you are a Mainland recruit or local recruit. : Mainland (If Local recruits the area should be indicated and also attach a copy of appointment /posting order) : Local 5. Designation : 6. Office in which presently working : 7. Category of employee (Group A/B/C/D) 8. Scale of Pay : Rs. 9. Basic Pay as on 1st of January of the year in which Application submitted : Rs. 10. Please state whether you are a part of joint family If so, does the joint family possess a house within the Municipal: Yes No Limits or within 20 Kms. from out side municipal limits. (*) Priority date of a Govt. servant in relation to type of residence to which is eligible under the provision of rule 7 means the earliest date from which he/she has been continuously drawing emoluments relevant to a particulars type or higher type in a post under the Administration or on foreign services, except for periods of leave. -2- 11.Please state whether any of your family members/spouse, parents, Children, leagally adopted children and sister ordinarily residing Yes No With you/owns or is in possession of house within the municipal limits or within 20 Kms from the outside municipal limits 12. Please furnish your present residential address: 13. Please state whether you have applied for House Building Loan 14. Please state whether you have been sanctioned House Building Loan. If yes please furnish details of sanction order. OORDER NO. & DATE AMOUNT SANCTIONED/APPLIED 15. Please also state whether you have applied for loan/assistance to build your own house from any source other than Government. II Details of Spouse 1. Name of spouse 2. If employed, state whether employed in Central Govt./ State Govt. PSU/ Central Govt. Organisation. 3. Name of Department/office/Organisation/PSU working in 4. Designation 5. Whether spouse, if working has been allotted Govt. accommoation at the same station. If yes details of quarter allotted Type Quarter No. Address: -3- 6. Copy of allotment order should be enclosed 7. Medical Certificate to be attached if quarter required near hospital. Signature of the Applicant. Certified that the information furnished by the Shri/Smti/Kumari_____________ ________________________working in ________________________as ____________ is correct as per records available with this office. Signature of HOD Name (in Block Letters) Designation (in Block Letters) Office Seal. -4- FOR OUT OF TURN ALLOTMENT (To be attached with Form-I) 1. Please state the reasons on which you deem justified for Out of Turn allotment. The certified copies of under mentioned documents are required for consideration. _______________________________________________________________ Requirements for processing the case for out of turn allotment on Medical/Compassionate/Tribal/Emergency duty grounds. 1. Original medical certificate from Govt. hospital duly signed by the Specialist and counter signed by the Medical Superintendent. It should not be more than a month old. (Please certify the relationship between the applicant and patient). 2. The request of the applicant giving the specific reasons for out of turn allotment. 3. Application Form I for allotment of Govt. accommodation under General Pool duly filled in by him and verified and endorsed by the competent authority. 4. Full particulars of present accommodation and details of family members living with the applicant. Please enclose an attested copy of ration card. 5. A certificate that the applicant has not applied earlier for adhoc allotment on medical grounds. In case he has applied earlier, he may be asked to give a full details. 6. In the case of TB, X-ray taken not more than a month prior to the date of the application. The X-Ray should contain the name of the patient. 7. Original medical certificate relating to physical disability/deformity from which a Govt. servant is and dependent parents suffering should be from a Medical Board consisting of Ortho Surgeion/Specialists/Head of Ortho and should be countersigned by the Medical Superintendent. 8. Full Photograph showing the extent of the disability/deformity duly attested by the doctor concerned. 9. A certificate to the effect that his/her father/mother is dependent on him. 10. In case of Tribal, A Certificate from competent authority may be submitted. (Please strike out the one which is not relevant).
