PERSONAL DETAILS PROFORMA FOR CIPET EMPLOYEES

(Note: Please write ”-NA-“ against columns which are not applicable in your case)

Employee ID
Employee Name
Gender
Marital Status
Father's Name
Spouse Name
Date of Birth
Physically Challenged
(Yes/No) Yes No

Ex-Servicemen (Yes/No)
Yes No

Category GEN OBC SC ST EWS

Religion
Caste
Permanent Address ______________________________________________________

______________________________________________________

_____________________________________________________

District __________________, State________________________

PINCODE ______________________________

Present Address
______________________________________________________
______________________________________________________
_____________________________________________________

District __________________, State________________________

PINCODE ______________________________

1
Home Town *
Home State
Mobile No
Contact No. in case of
Emergency
Email Id
PF No.
Period of service,
rendered under Contract
at CIPET, if any
Date of Joining on
Probation
Date of Joining as Trainee
if applicable
CIPET Centre
Present Designation
Present Department

Group
A B C
SUP/NON-SUP
SUP NON-SUP
Technical/Non-Technical
TECHNICAL NON-TECHNICAL

Pay
Pay Matrix Level Present Basic Pay

Date of Retirement
Aadhaar No.
PAN No.
Date of Confirmation
* Home Town once declared shall become final and cannot be changed generally except
under the applicable provisions and subject to approval of Competent Authority.

2
 EDUCATION DETAILS (AS ON DATE)
Degree as
awarded by
Mode
Sl. Year of Class / the
Qualification Board/University Duration of
No Passing Grade Institute/
Study
Universities
etc.,

DEPENDENT DETAILS(AS ON DATE)

Sl.
Dependent Name Relationship Date of Birth / Age Occupation
No.

3
 HISTORY OF SERVICE IN CIPET (AS ON DATE)
Pay Matrix Period
Sl. Basic Period
Designation Department Level and (To) Centre
No. Pay (From)
Cell

DETAILS OF PROMOTION (AS ON DATE)

Sl. Pay
Promotion Promotion Prev. Promoted Prev. Posted Prev. Posted
No Matrix
Order Date w.e.f Designation Designation Centre Centre Dept. Dept.
. Level

DETAILS OF TRANSFER (AS ON DATE)

Transfer Date of Joining
Sl. Prev. Posted Prev. Posted
Order at Transferred Designation
No. Centre ntre Department Department
Date Centre

4
 DETAILS OF AVAILED LTC (AS ON DATE)

Place of Date
Sl. No. Block Year Date (to) Relation
visit (From)

FOREIGN TOUR/TRAINING DETAILS (AS ON DATE)

Sl.
Place From Date To Date Purpose
No.

TRAINING DETAILS (AS ON DATE)

Sl. Place of
Name of Training From Date To Date
No. Training

REWARD DETAILS(AS ON DATE)

Sl. No. Reward Date Nature of Incident Nature of Reward

MEMO DETAILS (AS ON DATE)

Sl. No. Memo Date Memo Detail

5
 PUNISHMENT DETAILS, IF ANY (AS ON DATE)
Detail Of
Sl. No. Date (From) Date (To) Case Detail
Punishment

DECLARATION
I declare that the entries made in the columns of this proforma are correct and true to the best of my
knowledge and nothing has been either concealed or misrepresented by me. In case of any
misrepresentation, I understand that disciplinary action under the CIPET Conduct, Discipline and Appeal
Rules, 2018 may be taken against me.

Signature of CIPET employee

Name:__________________________

Designation:__________________

Dept: __________________________

Date:
CIPET Centre:

Signature of the Admin. In-Charge of the CIPET Centre