APPLICATION FORM TO BE SUBMITTED BY THE EX- SERVICEMEN/WIDOW/ORPHAN DEPENDENT FOR PRIORITY CERTIFICATE FOR EMPLOYMENT . PART 'A' Particulars of the deceased / severely disabled soldier (Delete whichever is not applicable ) 1. Service No. Rank 2. Name of deceased / severely disabled soldier 3. Operation in which killed / disabled 4. Date of death / disability 5. Name of Record Office PART 'B' NOMINATION FORM TO BE FILLED AND SIGNED BY THE WIDOW / PARENTS OF THE DECEASED SOLDIER. IN CASE OF DISABLED SOLDIER NOMINATION SHOULD BE MADE BY HIM ONLY. I. widow /father/ mother of deceased /severely disabled soldier (self) (Delete whichever is not applicable). Rank Name resident of village PO Tehsil District State do solemnly nominate Shri /Kumari /Smt. son / daughter / wife of resident of Village PO Tehsil District State for providing employment assistance as dependent under priority II.A so as to enable him/her to support me. Signature / Left thumb impression of the widow /mother /father of deceased /severely disabled soldier. PART 'C' Particulars of dependent of the soldier killed / severely disabled in war / peace (To be filled and signed by the dependent). 1. Name ( in Block letters) 2. Father's /Husband's Name 3. Complete address with PIN Code No. for correspondence. 4. Relationship with the deceased / severely disabled soldier. 5. Whether Scheduled Caste/ Scheduled Tribe /Physically Handicapped / Exserviceman (If belonging to any of the above category, submit a copy of certificate from competent authority ) 6. Date of Birth 7. Details of educational / technical qualification : Name of the examinations passed Subjects offered Division / percentage of marks Name of the Board / University Year of passing (1) (2) (3) (4) (5) (Attach separate sheet, if required) 8. whether knowing Typewriting / Shorthand (If yes, the language and speed per minute) 9. Details of present /past employment, if any 10. Type of job required /desired 11. Whether willing to service out of the State where residing? Yes / No If yes, the names of States (a) where willing to service in (b) the order of preference :-(c) 12. (a) Name of Employment Exchange where registered. (b) Registration No. (c) NCO Code No. 13. Any other information, desired to be given. I hereby declare that all information furnished above is true to the best of my knowledge and belief. I understand that in the event of any information being found false or incorrect, my case is liable to be rejected or cancelled. Signature / LTI of the dependent. Date: Place: PART 'D' FAMILY DETAILS OF THE DECEASED / SEVERELY DISABLED SOLDIER (To be filled by the widow/ parents of the deceased /severely disabled soldiers (Self) (Delete whichever is not applicable) Full family details if No. Rank Name Resident of village PO Teh Dist/State (a) Whether deceased / severely disabled soldier (b) Amount of pension / family pension Rs. p.m. was married or not (Write Yes/ No) (c) Name of recipient of pension / family pension. Sl No Name of each family member of the deceased / severely disabled soldier Present address Relationship with the deceased /severely disabled soldier Monthly income/ salary of family member qualifica tion Past/ present employ ment and experien ce Aids given by DGR/ Central/ State Govt. 1 2 3 4 5 6 7 8 (Attach separate sheet if required) I hereby declare that all the information furnished above is true and correct. Place: Signature of the widow/ Date: mother /father of the deceased / severely disabled soldier. PART ' E' Declaration to be given by the dependent (other than widows/ son/ daughter) who undertake to support the family of the deceased / severely disabled soldier (To be filled by the dependent) son/wife/daughter of resident of village PO Tensil District State do solemnly declare to maintain the family of No. Rank Name Regiment /Unit/Corps who was killed / severely disabled in operation / peace and whose particulars are given in Part "A" of the form, provided I am given a job / employment. Date: Signature of the dependent. PART 'F' (To be certified by the Record Office in case of PEACE TIME Deceased /severely disabled soldiers only) Certified that the particulars given in respect of deceased / severely disabled soldier in Part "A" of the form are correct. It is further certified that the death of deceased soldier whose particulars are given in Part "A" of the form has been accepted (ATTRIBUTABLE TO SERVICE (Naval /Air/Army) by Controller of Defence Accounts (P), Allahabad). It is further certified that the disability of the soldier whose particulars are given in Part "A" of the form has been accepted: (a) Attributable to service by CDA (P) Allahabad (b) Over 50% (write percentage of disability) (c) He has declared unfit for civil employment by the Medical Board at the time of discharge. (Delete whichever is not applicable) For Record Office (Give details of death /disability in brief i.e. Cause/ Nature / Place etc. whichever is possible / applicable) Date: Signature of Record Officer Place: Name Rubber stamp Office Seal IMPORTANT NOTE ; PLEASE ATTACH A CERTIFIED TRUE COPY OF CDA(P) ALLAHABAD LETTER ACCEPTING DEATH /DISABILITY OF ABOVE SOLDIER AS ATTRIBUTABLE TO MILITARY SERVICE WITH THE FORM PART 'G' Certificate to be given by the Secretary, Zila Sainik Board after thorough verification with the help of the civilian district authorities, where necessary (To be given by Secretary, Zila Sainik Board only) Certified that the information given in Part "A" to "F" in respect of No Rank Name (deceased /severely disabled soldier), his family and dependent Shri/ Kumari/ Smt (Write name of the dependent who seek employment) is found to be true and correct. Place: Signature Date: Name Office Seal / Stamp 1. In case Peace Time deceased /severely disabled soldier, this certificate should be given only after Part "F" of the form has been certified by Record Office and dependent is found eligible for employment assistance under Priority II (a) 2. Upto two dependents are only eligible for employment assistance under Priority II (a) 3. Dependents of only those disabled ex-servicemen are eligible for employment assistance under priority II (a) who were severely disabled with over 50% disability attributable to military service and declared unfit for civil employment by the medical board. 4. The form duly completed and certified may be forwarded by Zila Sainik Board to Ex.-servicemen Cell of Ministry of Labour whose address is given below (The forms received direct from the individuals are not accepted by Ex-servicemen Cell):- Director of Employment Exchanges. Ministry of Labour (DCE&T) EXSERVICEMEN CELL, 2A/ 3 Kundan Mansion, Asaf Ali Road, New Delhi 110 002. 5. Before forwarding the form of peace time dependents to Ex-servicemen Cell, please ensure that a copy of CDA(P) Allahabad letter / certificate to accepting death / disability of deceased / severely disabled soldier attributable to military service has been attached with the form.
