REGISTRATION FORM - EXSERVICEMEN 1. Number 2. Rank 3. Regiment / Corps 4. Name 5. Father's Name Stamp Size Photograph 6. Educational Qualification: Civil Service 7. Decoration 8. Character 9. Address Tehsil or Police Station Tele 10. Religion 11. Caste 12. Details of family (Wife, only dependent children upto 25 years and dependent parents) Name Age Relationship Educational Qualification (i) (ii) (iii) (iv) (v) (vi) (vii) 13. Date of Birth 14. Date of Enrolment 15. Date of Discharge 16. Reasons for discharge 17. Amount of Pension: (a) Service Pension Rs. (b) Disability Pension Rs. (c) Percentage of Disability 18. Lump sum payment Received: a) Gratuity Rs. b) Group Insurance Rs. c) Leave encashment Rs. d) Financial Assistance Rs. 19. Commuted Pension Rs. 20. Discharge Book No. & Date 21. P.P.O.No. & Date. 22. Present occupation & monthly income Service Rs. Business / Industry Rs. Agriculture Rs. Un-employed 23. Other relevant information, if any. 24. Identification Marks: 25. Left Thumb Impression: DECLARATION I hereby declare that the particulars given above are true to the best of my knowledge and belief. Date: Signature of Applicant. Place: FOR OFFICE USE Status as Ex-Servicemen : Yes / No. No. & Date of Identity Card issued. Date : Place: Signature Secretary, DSS&A Board with Office Stamp & Date.
