PROFORMA

I. SERVICE DETAILS:

1) NAME :

2) FATHER's' /HUSBAND's NAME :

3) DATE OF BIRTH :

4) PLACE OF BIRTH :

5.(a) EMPLOYEE I.D. No. :

(b) PAN No. IF INCOME TAX PAYEE :

6) DESIGNATION AND DATE OF ENTRY :

INTO SERVICE

7) PRESENT DESIGNATION AND PLACE :

OF WORKING

8) ZONE ALLOTTED : III

9. PROMOTIONAL PARTICULARS

S.NO: Designation Date of Date of joingning Remarks if any

Promotion in the post

II.SPOUSE PARTICULARS :

1 Name of the spouse :

2. Date of Marriage :
3. Status :
4. If employed, details of employment : ----
a. Designation and place of Working : ----
b. Name of employee : ----
c. Annual Income : ----
5. Pan No. If income tax assesses : ----
 PROPERTY DETAILS
A) IMMOVABLE PROPERTY (ACQUISITION OR DISPOSAL)

Name of Situation of Property Held in Date and mode Price and for Source or I incumbency Total worth of
property and Extent whose name of acquisition acquisition or payment designation and property as on
or disposal obtained for place of the day 1.6.07 In Rs.
disposal or acquisition of
property

1 2 3 4 5 6 7 8
 PROPERTY DETAILS
B) MOVABLE PROPERTY

Name of Held in whose Date and Name form Price paid for Source of Incumbency Total worth of
property name mode of Which property acquisition or Payment designation and property as on
acquisition or is aquired Obtained for place on the day 1.6.07 In Rs
disposal disposal of acquisition of
property
1 2 3 4 5 6 7 8
 PROPERTY DETAILS
B) MOVABLE PROPERTY

Name of Held in whose Date and Name form Price paid for Source of Incumbency Total worth of
property name mode of Which proposed acquisition or Payment designation and property as on
acquisition or is aquired Obtained for place on the day 1.6.07 In Rs
disposal disposal of acquisition of
property
1 2 3 4 5 6 7 8

B) SOURCES OF INCOME FROM DEPENDENTS

The year from which name is Total income from all sources
NAME Relationship
added
---- ---- NIL
----

CERTIFICATE

This is to certify that the service particulars furnished are verified from S.B. and found to be correct

Signature