dkfeZd laink izi=

Employee ID
Self Attested
GPF/DPF/PRAN/EPF Passport Size
Photo
(In case of new employee................to be filled by office)

1. O;fDrxr fooj.k% PERSONAL DETAILS

I 'kkldh; lsod dk iwjk uke@Full Name of Govt. employee - Jh@Shri Jherh@Smt. dqekjh@Kumari

First Name (In english & capital letter) -

Middle Name -
Last Name -
¼iwjk uke fgUnh esa lsok iqfLrdk ds vuqlkj½ -
II Father's Name (In english & capital letter) -
firk dk iwjk uke ¼fgUnh esa½ -
III Mother's Name (In english & capital letter)-
ekrk dk iwjk uke ¼fgUnh esa½ -

IV oxZ@Category - vukjf{kr@Unreserved v-fi-o-@OBC v-tk-@SC v-t-tk-@ST

V D;k 'kkldh; lsod fnO;kax gS & gk¡ ugha ¼;fn gk¡ gks rks fu/kkZfjr izk:i esa fpfdRlk izek.k&i= layXu djsa½

VI tUefrfFk vadksa esa@Date of Birth - 'kCnksa esa -

VII tUe LFkku@Place of Birth -
VIII tUe ns'k@Country of Birth -
IX jk"Vªh;rk@Nationality -
X x`g jkT;@Home State -
XI x`g ftyk@Home District -
XII fyax@Gender - iq:"k@Male efgyk@Female VªkUltsUMj@Transgender
XIII tkfr@Caste (In english & capital letter) -
XIV /keZ@Religion -
XV igpku fpUg@Identification Mark-In english & capital letter - 1 2
fgUnh esa & 1 2
XVI oSokfgd fLFkfr@Marital Status - fookfgr vfookfgr rykd'kqnk fo/kok@fo/kqj

XVII Spouse Name (In english & capital letter)

ifr@iRuh dk uke ¼fgUnh esa½
-
2-A. lEidZ fooj.k% CONTACT DETAILS
I orZeku vkoklh; irk@Present Residential Address (In english & capital letter)
orZeku vkoklh; irk & 'kkldh; vkokl futh vkokl ¼vko';d nLrkost layXu djsa½
Village/Town/Ward/Colony -
Land Mark -
Post Office -
Tehsil - District - State - Pin Code -

II LFkk;h irk@Permanent Address (In english & capital letter)

Åij ds leku@Same as above ¼;fn vU; gks rks uhps fy[ks@If other fill below fields)
Village/Town/Ward/Colony -
Land Mark -
Post Office -
Tehsil - District - State - Pin Code -

III Mobile Number - E-mail ID -

2-B. vU; fooj.k% OTHER DETAILS

I D;k vki viuk vk/kkj uacj dkfeZd lEink esa lk>k djus gsrq lger gSa \ & gk¡ ugha
vk/kkj la[;k@Aadhar Number - ¼lgefr i= layXu djsa½
II LFkk;h ys[kk la[;k@PAN No. -

2-C. dsoy lh ih ,l deZpkfj;ksa ds fy,% ONLY FOR CPS EMPLOYEE

I okf"kZd vk;@Income Range (Per Anum) -

5 yk[k ls de 5 yk[k ls 10 yk[k rd 10 yk[k ls 25 yk[k rd 25 yk[k ls vf/kd
II isa'ku Q.M p;u@Pension fund selection - 'kkldh; {ks=@Government Sector
LIC Pension Fund Limited SBI Pension Funds Private Limited UTI Retirement Solutions Limited
III
FATCA Compliance - Yes No

IV la;qDr jkT; vesfjdk dk O;fDr@USA person - Yes No

V izku dkMZ ¼PRAN CARD½ ij firk ds uke ds LFkku ij ekrk dk uke vafdr djkuk pkgrs gSa & gk¡ ugha
2-D. 'kS{[Link] ;ksX;rk% EDUCATIONAL QUALIFICATION (As on date of joining government Service)
[Link]. Name of Year of
Board/University Subject/Branch Division/Grade Remark
Examination Passing
 3. fu;qfDr@inLFkkiuk fooj.k% APPOINTMENT/POSTING DETAIL
I dsUæ@jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ lsok dk fooj.k ¼,d ls vf/kd iwoZ lsok gksus ij layXu izi= 3-I Hkjsa½ %
D;k dsUæ jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ dh lsok isa'ku@miknku [Link] gsrq vgZrknk;h lsok gS\ gk¡ ugha
;fn gk¡ gks rks fuEu fooj.k Hkjs &
¼1½ LFkkiuk dk izdkj & fu;fer dk;ZHkkfjr ,oa vkdfLedrk
¼2½ fu;qfDr dk izdkj & LFkk;h vLFkk;h vkikrh rnFkZ lafonk
¼3½ iz'kkldh; foHkkx dk uke &
¼4½ inuke &
¼5½ in dh [Link] & izFke f}rh; r`rh; ¼dk;Zikfyd½ r`rh; prqFkZ
¼6½ in xzg.k frfFk &
¼7½ lsokfuo`fRr@rduhdh R;kx&i= @HkkjeqDr frfFk &

II NÙkhlx<+ 'kklu ds v/khu izFke fu;qfDr dk fooj.k ¼ftl in ls fujarj dk;Zjr gSa½ %
¼1½ Loh— r in dk dSMj & jkT; ftyk vU; vf[ky Hkkjrh; laoxZ & IAS IPS IFS Other
¼2½ LFkkiuk dk izdkj & fu;fer dk;ZHkkfjr ,oa vkdfLedrk
¼3½ iz'kkldh; foHkkx dk uke &
¼4½ inuke &
¼5½ in dh [Link] & izFke f}rh; r`rh; ¼dk;Zikfyd½ r`rh; prqFkZ
¼6½ in xzg.k frfFk &
¼7½ osrueku@xzsM&is@ysoy &
¼8½ ewy osru & ¼9½ lsokfuo`fRr dh vk;q 62 65
¼10½ lsokfuo`fRr frfFk &
¼11½ fu;qfDr dk izdkj & LFkk;h vLFkk;h vkikrh rnFkZ lafonk
¼12½ fu;qfDr vkns'k Øekad &
¼13½ fu;qfDr vkns'k fnukad &
¼14½ fu;qfDrdrkZ vf/kdkjh dk inuke &
¼15½ foHkkxk/;{k dk uke &
¼16½ orZeku dk;kZy; dk uke ,oa irk &
¼17½ vkgj.k laforj.k vf/kdkjh dk inuke&
,oa dk;kZy; dk irk &
¼18½ vuqdEik fu;qfDr dh fLFkfr & gk¡ ugha
;fn gk¡ gks rks fuEu fooj.k Hkjsa %& e`rd 'kkldh; lsod dk deZpkjh dksM@ih ih vks uacj@uke

izFke fu;qfDr ds i'pkr~ LFkkukarj.k@inksUufr@uohu fu;qfDr@LrjksUu;u dk fooj.k layXu izi= 3-III esa Hkjsa ¼orZeku inLFkkiuk dks NksM+dj½A
III

IV NÙkhlx<+ 'kklu ds v/khu uohu fu;qfDr@orZeku inLFkkiuk dk fooj.k %

D;k orZeku inLFkkiuk ,oa izFke fu;qfDr leku gS \ gk¡ ugha ¼;fn ugha gks rks fuEu fooj.k Hkjsa½
 inLFkkiuk dk fooj.k & ¼tks ykxw gks djsa½
¼d½ uohu fu;qfDr & ¼[k½ inksUufr & ¼x½ LFkkukarj.k & ¼?k½ LrjksUu;u&[ØeksUufr le;eku ofj"B [Link]
foHkkxh; foHkkxh; foHkkxh; izoj [Link] ofj"B [Link] vf/kle; ]
vU; foHkkx izfrfu;qfDr@ckg~; lsok izfrfu;qfDr@ckg~;lsok foHkkxh; izfrfu;qfDr@ckg~;lsok

¼1½ Loh— r in dk dSMj & jkT; ftyk vU; vf[ky Hkkjrh; laoxZ & IAS IPS IFS Other
¼2½ LFkkiuk dk izdkj & fu;fer dk;ZHkkfjr ,oa vkdfLedrk
¼3½ fu;qfDr dk izdkj & LFkk;h vLFkk;h vkikrh rnFkZ lafonk
¼4½ iz'kkldh; foHkkx dk uke &
¼5½ inuke &
¼6½ in dh [Link] & izFke f}rh; r`rh; ¼dk;Zikfyd½ r`rh; prqFkZ
¼7½ in xzg.k frfFk &
¼8½ osrueku@xzsM&is@ysoy &
¼9½ ewy osru &
¼10½ vkxkeh okf"kZd osru o`f) frfFk &
¼11½ inLFkkiuk vkns'k Øekad &
¼12½ inLFkkiuk vkns'k fnukad &
¼13½ foHkkxk/;{k dk uke &
¼14½ orZeku dk;kZy; dk uke ,oa irk &

¼15½ fu;qfDrdrkZ@inksUuksfrdrkZ vf/kdkjh dk inuke &

¼16½ vkgj.k laforj.k vf/kdkjh dk inuke&
,oa dk;kZy; dk irk &

V ifjoh{kk vof/k dk fooj.k%

D;k 'kkldh; lsod dh fu;qfDr ifjoh{kk esa gqbZ gS@Fkh \ gka ugha
D;k 'kkldh; lsod }kjk ifjoh{kk vof/k [Link] dj yh xbZ gS \ gka ugha ¼;fn gk¡ gks rks fuEu fooj.k Hkjsa½
ifjoh{kk vof/k lekfIr dh frfFk &
vkns'k Øekad &

VI ifr@iRuh ds fu;kstu dk fooj.k%

D;k ifr@iRuh 'kkldh; fu;kstu esa gSa \ gka ugha
fu;kstu dh fLFkfr & dsUæ N-x- jkT; vU; jkT;@dsUæ 'kklu ¼;fn N-x- jkT; gks rks fuEu fooj.k Hkjsa½
ifr @ iRuh dk deZpkjh dksM &
Mh-Mh-vks- dksM &
dk;kZy; dk uke &
dk;kZy; dk irk &

4
 VII fofo/k fooj.k%
(a) fuyacu dh fLFkfr & gka ugha ¼;fn gk¡ gks rks fuEu fooj.k Hkjsa½

Ø- fuyacu dh frfFk cgkyh dh fLFkfr cgkyh dk vkns'k Øekad cgkyh dh frfFk

¼gk¡@ugha½

(b) foHkkxh; tkap dh fLFkfr & gka ugha ¼;fn gk¡ gks rks fuEu fooj.k Hkjsa½
Ø- foHkkxh; tkap dh fLFkfr foHkkxh; tkap vkns'k Øekad fnukad foHkkxh; tkap@fujkdj.k dk vkns'k
iwoZ orZeku izfr layXu@viyksM djsa

(c) D;k osru fu/kkZj.k dh tk¡p laHkkxh; la;qDr lapkyd dks"k ys[kk ,oa isa'ku dk;kZy; ls dh xbZ gS\ gk¡ ugha
;fn gka gks rks] laHkkxh; la;qDr lapkyd dks"k ys[kk ,oa isa'ku dk;kZy; dk uke &
,oa fnukad & osru fu/kkZj.k vuqeksnu@ tk¡p easa ;fn vf/kd Hkqxrku dh olwyh dh Vhi gS] rks
olwyh dh jkf'k :i;s-----------------------------------------------¼jkf'k :i;s dk;kZy; }kjk vafdr dh tk;s½
olwyh dh jkf'k ¼,deq'r½ :--------------------ns;d@pkyku Øekad& fnukad
;fn olwyh dh jkf'k fd'rksa esa dh xbZ gS rks fd'rksa dh la[;k-------------fd'r dh jkf'k---------------------- ns;d@pkyku Øekad ,oa frfFk
laca/kh tkudkjh layXu izi= 3-VII-C esa Hkjdj layXu djsaA
4. cSad fooj.k% BANK DETAILS
I [kkrs dk izdkj & cpr [kkrk (Saving A/C½ pkyw [kkrk (Current A/C)
II cSad [kkrk Øekad &
III cSad dk uke &
IV 'kk[kk dk uke &
V cSad@'kk[kk dk irk &
VI cSad ,e-vkbZ-lh-vkj-(MICR) dksM &
VII cSad vkbZ-,Q-,l-lh- (IFSC) dksM & fiu dksM &
VIII D;k cSad [kkrk Øekad vk/kkj ls fyad gS@Is Bank A/c No. linked with Adhar & gk¡ ugha
5-A. ifjokj fooj.k% FAMILY DETAILS
'kkldh; lsod
Øekad lnL; dk uke tUefrfFk ls lEcU/k vk/kkj uacj irk
 5-B. ukekadu fooj.k% NOMINEE DETAILS

Type Nominee in case of death/

Nominee Name (In case of madness/divorce
minor)
Relationship Share% Date of Remark
First Name Middle Last Name with govt. nomination First Name Middle Last Name
Name employee D.O.B. Guardian Name
Name

1 2 3 4 5 6 7 8 9 10 11 12 13

I lkekU; Hkfo"; fuf/k@foHkkxh; Hkfo"; fuf/k@uohu va'knk;h isa'ku ;kstuk [GPF/DPF/NPS (PRAN)]

1
2
3

II miknku [Gratuity]

1
2
3

III lewg chek ;kstuk [GIS]

1
2
3

IV ,Q-ch-,Q- [FBF]
1
2
3

'kkldh; lsod }kjk [Link].k % dk;kZy; izeq[k dk lR;kiu

[Link] fd;k tkrk gS fd Jh@Jherh@lqJh------------------------------------------------------------------
[Link] fd;k tkrk gS fd mijksDr fooj.k ds }kjk fn;s x;s fooj.k dk lsokiqfLrdk ,oa dk;kZy;hu vfHkys[kksa ls feyku fd;k x;k gSA
esjh tkudkjh ,oa Kku ds vuqlkj lR; rnkuqlkj mijksDr fooj.k lgh ik;k x;k gSA
,oa lgh gSA
vf/kdkjh ds gLrk{kj % --------------------------------------------------------------------
'kkldh; lsod dk gLrk{kj inuke ,oa ineqæk % --------------------------------------------------------------------
--------------------------------------------------------------------
--------------------------------------------------------------------
dk;kZy; dk uke ,oa irk % --------------------------------------------------------------------
--------------------------------------------------------------------
fnukad % -----------------
--------------------------------------------------------------------
LFkku % ----------------- fnukad % --------------------------------------------------------------------
 deZpkjh MkVkcsl izi= esa layXu fd;s tkus okys nLrkostksa dh lwph : ¼[Link] izfr layXu djsa½

lkW¶Vos;j esa viyksM fd;s tkus okys

Øekad nLrkost fpfUgr djsa nLrkostksa dk fu/kkZfjr izk:i
i QksVks Size 04 to 12 KB (JPG Format)
ii deZpkjh dk uewuk gLrk{kj Size 04 to 12 KB (JPG Format)
iii 'kS{[Link] ;ksX;rk laca/kh vad lwph] tUefrfFk gsrq Size 40 to 100 KB (JPG Format)
tUe izek.k i=@gkbZ Ldwy lfVZfQdsV ijh{kk izek.k i=
iv vk/kkj dkMZ Size 40 to 100 KB (JPG Format)
v isu dkMZ Size 40 to 100 KB (JPG Format)
vi fuokl dk irk laca/kh vfHkys[k ¼Mh,y] oksVj vkbZMh] ikliksVZ vkfn½ Size 40 to 100 KB (JPG Format)
vii cSad iklcqd dk izFke i`"B Size 40 to 100 KB (JPG Format)
viii lfoZl cqd dk izFke i`"B fooj.k i`"B Size 40 to 100 KB (JPG Format)
ix lfoZl cqd dk ukekadu fooj.k i`"B Size 40 to 100 KB (JPG Format)
x tkfr izek.k i= Size 40 to 100 KB (JPG Format)
xi nRrd iq=@iq=h izek.k i= Size 40 to 100 KB (JPG Format)
xii fnO;kaxrk dh fLFkfr esa fpfdRlk izek.k i= Size 40 to 100 KB (JPG Format)
xiii ckg~;lsok@izfrfu;qfDr ds ekeys esa vkns'k dh izfr Size 40 to 100 KB (JPG Format)
xiv fuyacu dh fLFkfr esa vkns'k dh izfr Size 40 to 100 KB (JPG Format)
xv fuyacu ls cgkyh dh fLFkfr esa vkns'k dh izfr Size 40 to 100 KB (JPG Format)
xvi ifjoh{kk vof/k lekfIr vkns'k dh izfr Size 40 to 100 KB (JPG Format)
xvii 'kkldh;@futh vkokl laca/kh vfHkys[k Size 40 to 100 KB (JPG Format)
xviii vf/kd Hkqxrku dh olwyh laca/kh vfHkys[k Size 40 to 100 KB (JPG Format)

¼Vhi&rkjkafdr nLrkostksa dks vfuok;Z :i ls layXu djsaA½

 izi= 3-I
dsUæ@jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ lsok dk fooj.k %
D;k dsUæ jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ dh lsok isa'ku@miknku [Link] gsrq vgZrknk;h lsok gS\ gk¡ ugha
;fn gk¡ gks rks fuEu fooj.k Hkjs &
LFkkiuk dk izdkj & fu;fer dk;ZHkkfjr ,oa vkdfLedrk
fu;qfDr dk izdkj & LFkk;h vLFkk;h vkikrh; rnFkZ lafonk
inuke &
in dh [Link] & izFke f}rh; r`rh; ¼dk;Zikfyd½ r`rh; prqFkZ
in xzg.k frfFk &
lsokfuo`fRr@HkkjeqDr frfFk &
iz'kkldh; foHkkx dk uke &

izi= 3-I
dsUæ@jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ lsok dk fooj.k %
D;k dsUæ jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ dh lsok isa'ku@miknku [Link] gsrq vgZrknk;h lsok gS\ gk¡ ugha
;fn gk¡ gks rks fuEu fooj.k Hkjs &
LFkkiuk dk izdkj & fu;fer dk;ZHkkfjr ,oa vkdfLedrk
fu;qfDr dk izdkj & LFkk;h vLFkk;h vkikrh; rnFkZ lafonk
inuke &
in dh [Link] & izFke f}rh; r`rh; ¼dk;Zikfyd½ r`rh; prqFkZ
in xzg.k frfFk &
lsokfuo`fRr@HkkjeqDr frfFk &
iz'kkldh; foHkkx dk uke &

izi= 3-I
dsUæ@jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ lsok dk fooj.k %
D;k dsUæ jkT; ¼NÙkhlx<+@e/;izns'k½ 'kklu ds v/khu iwoZ dh lsok isa'ku@miknku [Link] gsrq vgZrknk;h lsok gS\ gk¡ ugha
;fn gk¡ gks rks fuEu fooj.k Hkjs &
LFkkiuk dk izdkj & fu;fer dk;ZHkkfjr ,oa vkdfLedrk
fu;qfDr dk izdkj & LFkk;h vLFkk;h vkikrh; rnFkZ lafonk
inuke &
in dh [Link] & izFke f}rh; r`rh; ¼dk;Zikfyd½ r`rh; prqFkZ
in xzg.k frfFk &
lsokfuo`fRr@HkkjeqDr frfFk &
iz'kkldh; foHkkx dk uke &
 [Link]
lafonk vf/kdkjh@deZpkjh gsrq MkVkcsl izi= QksVks

1 lafonk vf/kdkjh@deZpkjh dk uke izFke uke e/; uke vafre uke

¼fgUnh esa½
¼vaxzsth esa½
2 firk dk uke ¼fgUnh esa½
firk dk uke ¼vaxzsth esa½
3 ekrk dk uke ¼fgUnh esa½
ekrk dk uke ¼vaxzsth esa½
4 oxZ ¼ djsa½ vtk vttk vfio lkekU;
5 fyax ¼ djsa½ iq:"k efgyk Vª[Link]
6 tUefrfFk
7 D;k iwoZ esa Hkh lafonk fu;qfDr gqbZ gS \ & gk¡ ugha
;fn gk¡ rks iwoZ lafonk vof/k dk fooj.k fuEukuqlkj vafdr djsa %&
Øekad vkns'k Øekad fnukad lafonk izkjaHk frfFk lafonk lekfIr frfFk

8 fu;qfDr vkns'k Øekad fnukad

9 lafonk inxzg.k frfFk ekg o"kZ
10 orZeku lafonk lekfIr frfFk ekg o"kZ
11 foHkkx dk uke
12 dk;kZy; dk uke
13 inuke
14 in dh [Link]
15 lafonk osru
16 iSu ¼PAN½ uacj
17 i=kpkj dk orZeku irk
18 x`g ftyk 19 jkT;
20 eksckbZy uacj
21 bZ&esy vkbZ-Mh-
22 cSad dk fooj.k %
cSad rFkk 'kk[kk dk uke
vkbZ-,Q-,l-lh-
[kkrk Øekad
23 'kS{[Link] ;ksX;rk %
ijh{kk dk uke o"kZ cksMZ@fo'ofo|ky; dk uke fo"k; [Link]

lafonk deZpkjh dk gLrk{kj vkgj.k ,oa laforj.k vf/kdkjh dk gLrk{kj

 çi= 3-III
izFke fu;qfDr ds i'pkr~ LFkkukarj.k@inksUufr@uohu fu;qfDr@LrjksUu;u dk fooj.k Hkjsa ¼orZeku inLFkkiuk dks NksM+dj½ &
inLFkkiuk dk fooj.k ¼tks ykxw gks djsa½
l-
Ø- uohu fu;qfDr inksUufr LFkkukarj.k LrjksUu;u osrueku osrueku@ vkns'k Ø- inHkkj dk;ZeqDr dk;kZy; foHkkx
xzsM&is@ ,oa xzg.k frfFk dk uke dk
fo v fo izfrfu;qfDr fo izfrfu;qfDr Ø l o iz ofj"B v ysoy fnukad frfFk ,oa irk uke
Hkk U; Hkk @ckg~; lsok Hkk @ckg~; lsok eks e fj o izoj f/k
xh fo xh xh Uu ; "B j [Link] l
; Hkk ; ; fr ek Js Js e
x u .kh .kh ;
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19