Appendix ‘C’
REGISTRATION FORM-EX-SERVICEMEN
1. Number ______________
2. Rank ____________
3. Regiment/Corps ______________
4. Name ____________________________________________
5. Father’s Name _____________________________________
6. Education 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 Education
Qualification
i)
ii)
iii)
iv)
v)
vi)
vii)
13. Date of Birth __________________
14. Date of Enrolment ________________________
15. Date of Discharge ___________________
16. Reason for discharge _________________
17. Amount of Pension;
(a) Service Pension Rs. ________________________________
(b) Disability Pension Rs. _______________________________
(c) Percentage of Discharge _____________________________
18. Lumpsum 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. PPO 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-serviceman Yes/No
No. & Date of Identity Card Issued __________________
Date: _____________________
Place : ___________________ (Signature Zila Kalyan Officer/Kalyan)
Evam Punarvas
Officer/Secretary
ZSB with office Stamp & date