Application No. Application D ate APPLICATION FOR QUARTERS ( Put tick m ark (P)toselectwhicheverisapplicable ) Office Secretariat Head of Department District Others Category Space for Stamp Size Photograph (for Non-Government applicants) Principal Secy. / Comm.-cum-Secy / Addl. Secy / Jt. Secy / Dy. Secy / Under Secy Govt. of India Employee Employee of Board / Corporation / Private Essential Services Sports Person NGO Deputed to Govt. of India National/State Award Winner Media Person Others Specify details: 1. Personal Details (In Block Letters) B. Father's / Husband's Name E-mail _________________________@___________________________________________________________ 2. Present Posting Details (i) Designation___________________________ (ii) Department/Organisation ____________________________ (iii) Scale of Pay __________________________ (iv) Present Basic Pay ___________________________ (v) Gazetted Non-Gazetted (vi) Group A B C D 3. Marital Status : Single Married Widow Childless Widow 4. Health Status of Applicant /: Blind Cancer Paralysis Polio Heart Surgery Kidney Surgery None Dependant ( Give details and attach certificate as applicable) 5. Any quarter allotted to: Father Mother Spouse Son Unmarried Daughter None If allotted, Specify Qr. Type____ Qr. No______ Area _______________ Date of Allotment___________Order No.______/__________ 6. Any House at Bhubaneswar : Self Spouse Son Unmarried daughter None If yes, Plot No. ___________, Area _______________________, PO ________________ PIN _____________ 7. Applicant appointed under Rehabilitation Scheme? - Yes/No 8. Willing for joint accommodation? - Yes / No 9. Willing to avail lower type, in case entitlement is not available? - Yes / No 10. The area of choice in order of preference 1) 2) 3) 11.Whether any GA Quarter was previously allotted? - Yes / No If Yes, give details Qr. Type ____ Qr. No______ Area _____________Period: From_________ To________ Order No. _______/___________ Whether any penal action has been taken for non-vacation of quarters? Yes / No, (If Yes, Give Details) 12. Remarks: Signature of the Applicant The application of Shri / Smt/Ms. ______________________________ is recommended for consideration of new allotment / exchange of quarter. Signature of Secretary to Government / Date: Head of the Department / Head of Office/ Authorised Sponserer ( with seal ) Check List ( For office use only ) Necessary document(s) regarding category Affidavit of no allotment of quarters to near relatives Affidavit regarding no penal action for non-vacation of quarters Rehabilitation Scheme Appointment Order Affidavit of not having house at Bhubaneswar Stamp size photograph Medical Certificate Award Certificate Proof of Sportsperson Others Signature of Verifying Officer ( Acknowledgement ) Application No. & Date Date of Receiving the Application Received application of Shri / Smt/Ms.______________________________________, Designation ____________________ of ________________________________ for new allotment / exchange of quarters. Please refer your Application No. or GPF No. for further enquiry. Signature of Receiving Officer Following Documents are not available with your application 1. 2. 3. 4.
