(A Court Fee Stamp of Rupees Two should be affixed to the Application Form) Form of Application for Employment under the Scheme for the Composslonate Employment of the departments of Government Servants Dying-in - Harness Contemplated in G.O.(P)12/99/P&ARD dated 24-05-1999 1. Name and full postal address of the Applicant indicating the name of the District. : 2. Name, full residential address and details Of appointment last held by the Government Servant together with details of the date of Entry in service, office and department where Worked immediately before death etc. : 3. Relationship of the applicant to the Government Servant who died-in-harness : 4. Total continuous service put in by the deceased Government Servant with dates of birth and death : 5. Details of the members in the family of the Deceased Government Servant together with the Name, age occupation and relationship of each With the deceased : 6. Total annual family income of the deceased Government Servant (certificate from concerned Authority should be attached) : 7. Applicant's age and date of birth (attested copy Of the relevant school records or other relevant Records should be attached) 8. Educational qualifications and experience, if any, Gained (attested copy of the certificate to be attached) : 9. Physical measurements and fitness(need be Filled by the applicant who apply for the posts Of Police Constable, Excise Guard, Forest Guard or Jail Warden) : Height : Chest-Normal Chest - Expanded (To be supported by a certificate from a Medical Officer in Government Service) : : 10. Whether the applicant is married or single ? : 11. Whether the applicant or any other dependent of The deceased Government Servant had applied For the benefit under the scheme earlier ? (If so Give details) : 12. Whether any other department of the deceased Government Servant has availed of the benefit of Employment under the scheme previously ? : 13. Name of posts for which appointment is sought In the order of preference : 14. The District chosen by the applicant : DECLARATION I,................. do hereby declare that the particulars given above are true to the best my knowledge and belief, I also agree to that the appointment secured by me under the scheme being terminated without notice in the event of finding any misrepresentation or suppression of material facts on my part. Signature of applicant. Place : Date :
