Application for appointment on Compassionate ground for Group ‘C’ / ‘D’ post

I. Particulars of the deceased /Medically Unfitted in all classes /decategorised/Missing Employee:

1 Name of the employee

2 Designation/Shop/Tkt No.

3 Emp.No.

4 Community (SC/ST/OBC/UR)

5 Date of cessation of service

6 Nature : Demise / MU in all classes / Med. Decategorisation/ Missing
7 Office Order No. and Date

2. Family composition

Sl.No Name Date of Birth/
AGE Relationship Marital Status Occupation, (if any, with details) Remarks

--2—
3. Details of settlement received:

Sl.No. Details Amount Beneficiery
1 DCRG

2 Group Insurance

3 PF

4 Leave Salary

5 Pension/Family Pension

4. Particulars of the applicant for compassionate ground appointment:

1. Name
2. Relationship
3. Date of birth and age
(Proof to be enclosed)
4. Educational qualification
Academic:

Technical;
(Proof to be enclosed)
5. Community(SC/ST/OBC/UR)
(Proof for SC/ST/OBC to be enclosed)
6. Occupation, if any, with details

7. Marital status
8. Contact telephone number
9. Information, if any
10. Address for communication

The details furnished above are true and there is no suppression of facts.

Signature of the leading member of Signature of the applicant
the family. (Father/Mother) Date

-3-

5. I/We have no objection in considering the candidature of Shri/Smt/Ms______________________for compassionate ground appointment in ICF/Chennai – 38.

Sl.No Name Relationship Signature
1

2

3

4

Forwarded to OS/Con along with report, undertaking form and pass declaration collected from Shop/Office

Staff and Welfare Inspector/Shell/Fur:
Date: