CHECKLIST FOR INCUMBENT JOINING PGIMER SERVICES

S.No. Particulars Tick ()

1. Appointment acceptance letter.
2. Joining Report.
Form of intimation for applying of outside employment prior to joining
3.
PGIMER services.
4. Form of Attestation (in triplicate).
5. Form for Family details (in duplicate).
6. Form for Home Town Declaration (in duplicate).
7. Form for Marital Declaration (in duplicate).
8. Form for Oath of Allegiance (in duplicate).
9. Form for Oath of Secrecy (in duplicate).
10. Form for PRAN (NPS Account Opening).
11. Form for NPS Option (in duplicate).
12. Form for nomination under CGEGIS 1980 (in duplicate).
13. Form for Legal Undertaking.
14. Form for Property Return (Moveable/Immovable, Asset & Liability).
15. Form for claiming House Rent Allowance (HRA).
16. Form for claiming Travelling Allowance (TA).
17. Form for issuance of Identity Card.
18. Form of Personal Information.
19. Form of Bio-Data.
Form for joint declaration by spouse if employed with other Govt.
20.
organization for availing medical facility from PGIMER, if applicable.
21. Form of Registration for Staff Clinic.
Form for availing the facility of Staff Clinic along with affidavit and two group
22. photograph with family, if parents are dependent, otherwise group
photograph with spouse and children only.
23. Form of Character Certificate.
24. Copy of relieving Order, if applicable.
25. Copy of NOC from previous employer, if applicable.
26. Copies of Educational Qualification i.e. marksheets/certificates.
27. Copy of Experience Certificate(s), if applicable.
28. Copy of Caste Certificate, if applicable.
29. Copy of Divyang Certificate, if applicable.
30. Copy of Aadhaar.
31. Copy of PAN.
32. Copy of Bank Passbook (State Bank of India only).
32. Medical Fitness Certificate (to be conducted by PGIMER Chandigarh).
33. Passport Size photographs (ten copies)

NOTE: Submit Form at S.No.10, S.No.15, S.No.16, S.No.17 and S.No.20 to 22 to NPS Section (2nd Floor,
Kairon Block), Estate Branch, Transport Department (Nehru Hospital), Committee Branch, (1st Floor, Kairon
Block) and Staff Clinic (3rd Floor, New OPD) respectively. The rest of the Forms/document shall be submitted
to the Establishment Branch on the day of joining. The one set of Forms mentioned at S.No.5, 6, 7, 8, 9, 11
& 12 shall be submitted to the Service Book Section (1st Floor, Kairon Block).
 ACCEPTANCE LETTER

To,
The Director
PGIMER Chandigarh

Sub: Acceptance of the appointment.

Ref.: Your appointment letter no.______________ dated ____________.

Sir,

As per the appointment letter under reference, I wish to inform you that I am
willing to accept the appointment as per the terms and conditions mentioned in
the letter.

*I shall report for joining on or before _______________________.

OR

*I am willing to join the Institute, but for the reasons mentioned below I need
extension of _____ days for joining. I shall join on or before ______________. I
understand that the extension is at the discretion of the Director, PGIMER
Chandigarh and the decision shall be acceptable to me.

Reasons for extension:

Yours sincerely,

____________________________ Signature
____________________________ Date
_____________________________________________________ Name
_____________________________________________________ Address
_____________________________________________________
_____________________________________________________
* Strike out that is not applicable.
 JOINING REPORT
To,
The Director
PGIMER Chandigarh

Sub: Joining Report.

Ref.: Your appointment letter no.______________ dated ____________.

Sir,

With reference to the above, I__________________________________________

joined as _____________________________________________________ in the
Institute on ________________________(FN/AN).

The terms and conditions mentioned in the appointment letter are acceptable to
me.

Yours sincerely,

____________________________ Signature
____________________________ Date
________________________________________ Name

FOR ESTABLISHMENT SECTION USE ONLY

The candidate has joined duty on _______________________ (FN/AN). The

joining of the candidate may be accepted subject to the Bio-Metric verification.

Dealing Asstt. OS/AAO/AO

To,
The Director
PGIMER Chandigarh

Sub: Intimation regarding applying of outside employment prior to joining

PGIMER services.

Sir,

It is to inform you that before joining the PGIMER Chandigarh services, I have
applied for the following posts:

a)_______________________________________________________________
b)_______________________________________________________________
c)_______________________________________________________________
d)_______________________________________________________________
e)_______________________________________________________________
f)_______________________________________________________________
g)_______________________________________________________________
h)_______________________________________________________________

This is for your kind information and record, please.

Yours sincerely,

Signature
Name______________________
Date:____________________
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
mEehnokj }kjk viuh fy[kkoV esa gh Hkjk tkuk pkfg;sA
To be filled in by the candidate in his own handwriting. gky gh ds ikliksVZ vkdkj
¼3-5 ls-eh- x 4-5 ls-eh-½ ds
gLRkk{kfjr QksVks dh izfr
lk{;kadu QkeZ@ ATTESTATION FORM fpidkb,
psrkouh@WARNING Affix singed Passport
size (3.5 cm x 4.5 cm
approx.) copy of recent
photograph

1- lk{;kadu QkeZ esa >wBh lwpuk nsuk ;k fdlh rF; dks fNikuk vugZrk le>h tk,xh rFkk mlds dkj.k mEehnokj dks
ljdkjh ukSdjh ds fy, v;ksX; le>s tkus dh laHkkouk gSA
The furnishing of false information or suppression of any factual information in the Attestation form would be a
disqualification and is likely to render the candidate unfit for employment under the government.

2- bl QkeZ dks Hkjus vkSj Hkstus ds ckn ;fn mEehnokj dks utjcUn] fxjQrkj fd;k tkrk gS] ml ij eqdnek pyk;k
tkrk gS] cUnh] tqekZuk] nf.Mr] fooftZr] nks’keqÙk vkfn fd;k tkrk gS rks mldh lwpuk rRdky funs'kd] LukrdksÙkj
fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ dks vFkok ml vf/kdkjh dks ;FkkfLFkfr Hksth tkuh pkfg;s] ftldks igys
lk{;kadu QkeZ Hkstk x;k gSA ,slk u djus ij ;g le>k tk;sxk fd okLrfod lwpuk fNikbZ xbZ gSA
If detained, convicted, debarred, etc. subsequent to the completion and submission of this form, the details should be
communicated immediately to the Director, Postgraduate Institute of Medical Education & Research, Chandigarh or the
authority to whom the attestation form has been sent earlier, as the case may be. Failure to do so will be deemed to be
suppression of factual information.

3- ;fn fdlh O;fDr ds lsokdky esa ;g irk pyrk gS fd lk{;kadu QkeZ esa >wBh lwpuk nsuk ;k fdlh rF; dks fNik;k
x;k gS rks mldh lsok,a lekIRk dh tk ldsaxhA
If the fact that false information has been furnished or that there has been suppression of any factual information in the
attestation form, comes to notice at any time, during the service of a person, his service would be liable to be terminated.

1- iwjk uke ¼lkQ v{kjksa esa½ miukeksa lfgr miuke@Surname uke@Name

¼;fn vkius vius uke ;k miuke esa fdlh
le; dqN c<+k;k ;k ?kVk;k gS rks d`Ik;k
crk,aA½
Name in full (IN BLOCK CAPITALS) with
aliases, if any (please indicate if you added or
dropped at any stage any part of your name
or surname).
2- orZeku iwjk irk ¼vFkkZr~ xzke] Fkkuk vkSj
ftyk ;k edku u-] xyh@lM+d@ekxZ vkSj
uxj½
Present address in full (IN BLOCK CAPITALS)
(i.e. Village, Thana and Distt. or House No;
Lane/Street/Road and Town)
3- ¼d½ ?kj dk iwjk irk ¼vFkkZr~ xzke] Fkkuk
vkSj ftyk ;k edku u-] xyh@lM+d@ekxZ
vkSj uxj vkSj ftys ds eq[;ky; dk uke½
(a) Home Address in full (IN BLOCK
CAPITALS) (i.e. Village, Thana any Distt. or
House No., Lane/Street/Road and Town)
¼[k½ ;fn ikfdLrku dk ewy fuoklh gS rks
ml ns’k esa irk vkSj Hkkjr la?k esa iztuu
dh rkjh[kA
(b) If originally a resident of Pakistan, the
address in that country and the date of
migration to the Indian Union

The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 1

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
4- mu LFkkukssa dk C;kSjk ¼jgus dh vof/k;ksa lfgr½ tgka vki fiNys ikap o"kksZ esa ,d o"kZ ls vf/kd le; rd jgs gksaA ;fn
fons’kksa ¼ikfdLrku lfgr½ jgs gksa rks mu LFkkuksa dk C;kSjk nsuk pkfg, tgka vki ,d o"kZ ls vf/kd le; rd 21 o"kZ dh
vk;q gksus ds ckn jgs gksAa
Particulars of Place (with periods of residences) where you have resided for more than one year at time during the preceding
five years. In case of stay abroad (including Pakistan). Particulars of all places where you have resided for more than one year,
after attaining the age of 21 years should be given

vof/k@Period fuokl LFkkuksa ds iwjs irs ¼vFkkZr~ xzke] Fkkuk vkSj fiNys [kkus esa fn;s x;s LFkku ds
ftyk ;k edku u-] xyh@lM+d@ekxZ vkSj uxj½ ftys ds eq[;ky; dk uke
dc ls@From dc rd@To Residential address in full (i.e.), Village, Thana & Distt. or Name of the Dist. H.O. of the place
House No/ Lane/Street/ Road & Town mentioned in the preceding column

5- ¼d½ (a)
O;olk; ¼;fn lsok esa
gks rks iwjk inuke orZeku Mkd dk irk
jk"Vªh;rk ¼tUe ls
vkSj dk;kZy; dk iwjk ¼;fn e`rd gks rks ?kj dk LFkkbZ irk
vkSj@;k vf/kokl ls½
fj'rk uke Nationality (by
tUe dk LFkku irk fn;k tk;s½ fiNyk irk½ Permanent
Relation Name Place of birth Occupation (if Present Postal
birth and/or Home address
employed give full address (if dead
by domicile)
designation & give last address)
Official address)
(i) firk ¼iwjk uke]
miukeksa lfgr ;fn
dksbZ gks½
Father (Name in full
aliases, if any)

(ii) ekrk Mother

(iii) iRuh@ifr
Wife/Husband

(iv) HkkbZ Brother(s)

(v) cgusas Sister(s)

The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 2

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
¼[k½ fons’k esa i<+ jgs@jg jgs iq= ¼iq=ks½a vkSj@;k iq=h ¼iqf=;ksa½ ds ekeys esa izLrqr dh tkus okyh lqpukA
(b) Information to be furnished with regard to son(s) and/or daughter(s) in case they are studying/living in a foreign country.

jk"Vªh;rk ¼tUe ls ns'k dk uke tgka i<+ fiNys dkye esa fn;s x;s ns'k esa
vkSj@;k vf/kokl ls½ jgs@jg jgs gSa iwjk irk ftl rkjh[k ls jgs gS
tUe dk LFkku
uke Name Nationality (by
Place of birth
Country in which Date from which
birth and/or by studying/ living with studying/living in the country
domicile) full address mention in previous column

6. (i) firk dh jk"Vªh;rk Nationality of Father (i)

(ii) ekrk dh jk"Vªh;rk Nationality of Mother (ii)
(iii) ifr ;k iRuh dh jk"Vªh;rk Nationality of Spouse (iii)
(iv) vH;FkhZ dh jk"Vªh;rk Nationality of Candidate (iv)
(v) ifr ;k iRuh dk tUeLFkku Place of birth of Spouse (v)

7. (i) tUe dh rkjh[k ¼bZLoh laor~ esa½ Date of birth (in Christian era) (i)
(ii) orZeku vk;q@Present age (ii)
(iii) esfVªd ds le; vk;q@Age at Matriculation (iii)
(iv) tkfr ¼lkekU;@vuqlfw pr tkfr@ vuqlfw pr tutkfr@
(iv)
vU; fiNM+k oxZ½@Category (UR/SC/ST/OBC)
(v) fodykaxrk ¼vks-,p-@,p-,p-@oh-,p-½@
(v)
Person with Disability (OH/HH/VH)
(vi) /keZ@Religion (vi)

(i)
8. O;fDrxr igpku dh fu'kkuh
Personal Marks of identification (ii)

9. (i) tUe LFkku] ftyk vkSj jkT; ftlesa ;g fLFkr gS

(i)
Place of birth, Distt & State in which situated
(ii) vki fdl ftys vkSj jkT; ds gS
(ii)
Distt. & State to which you belong
(iii) vkids firk ewy #i ls fdl ftys vkSj jkT; ds gS
(iii)
Distt. & State to which your father belongs

10. 15 o"kZ dh vk;q ls fdu&fdu Ldwyksa vkSj dkystksa esa vkSj fdu&fdu o"kksZ esa f’k{kk izkIr dh mlds LFkkuksa dks o"kksZ ds lkFk fn[kkrs gq, f’k{kk laca/kh ;ksX;rk,aA
th
Educational qualifications showing places of education with years in Schools and College since the 15 Year age.

Ldwy@dkyst dk uke vkSj iwjk irk izos'k dh rkjh[k NksM+us dh rkjh[k ijh{kk mrhZ.k dh
Name of School/College with full address Date of entering Date of Leaving Examination Passed

The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 3

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
11- ¼d½ D;k vki bl le; dsfUnz; ;k jkT; ljdkj ;k v/kZ&ljdkjh ;k LFkk;hor~ ljdkjh fudk; ;k Lo’kklh fudk; ;k lkoZtfud midze ;k fdlh
xSj ljdkjh midze ;k laLFkk ds vUrxZr dk;Z dj jgs gSa ;k igys dHkh dk;Z fd;k gS\ ;fn gk¡] rks fu;ksDrk dh rkjh[k lfgr iw.kZ fooj.k nsAa
(a) Are you holding or have any time held an appointment under the Central or State Government or a semi-Government or a quasi-
Government body or an autonomous body, or a public undertaking or a private firm or institution? If so, give full particulars with dates of
employments up-to-dates:
vof/k@Period in] ifjyfC/k;ka rFkk jkstxkj dk igyh ukSdjh NksM+us dk
Lo#i fu;ksDrk dk iwjk uke o iRkk dkj.k
dc ls@From dc rd@To Designation, emoluments and Full name and address of employer Reasons of leaving
nature of employment previous service

11- ¼[k½ D;k fiNyh lsok Hkkjr ljdkj@jkT; ljdkj@Hkkjr ljdkj ;k fdlh jkT; ljdkj ds LokfeRo ;k
lapkfyr fdlh midze] fdlh Lok;r~ fudk;] fo’ofo|ky;@LFkkuh; fudk; ds v/khu Fkh] ;fn vkius dsUnzh;
flfoy lsok;sa ¼vLFkkbZ lsok½ fu;e] 1965 ds fu;e 5 ds v/khu ;k fdUgha blh izdkj ds fu;eksa ds v/khu ,d
eghus dk uksfVl nsdj lsok NksM+h Fkh rks D;k vkids fo#) dksbZ vuq'kklfud dk;Zokgh dh xbZ Fkh ;k tc
vkidh lsok dks lekIr djus ds fy, uksfVl fn;k x;k Fkk ;k ckn esa vkidh lsok ds okLro esa lekIr gksus ls
igys rd vkils fdlh ekeys esa vkids vkpj.k ds fy, Li"Vhdj.k ekaxk x;k Fkk\

(b) If the previous employment was under the Govt. of India/State Govt. /an Undertaking owned of
Controlled by the Govt. of India or a State Govt. /an autonomous body/university/ Local body. If you had
left service on giving a month notice under Rule 5 of the Central Civil Services (Temporary Service) Rules,
1965 or any similar corresponding rules were any disciplinary proceedings framed against you, or had you
been called upon to explain your conduct in any matter at the time you gave notice of termination of
service, or at a subsequent date before your services actually terminated?

12- ¼d½ D;k vki dHkh fxjQrkj fd;s x;s\
¼[k½ D;k vki ij dHkh eqdnek pyk gS\
¼x½ D;k vki dHkh utjcan j[ks x;s\
¼?k½ D;k vki dHkh canh cuk;s x;s\
¼M+½ D;k vki ij fdlh fof/k
U;k;ky; }kjk tqekZuk fd;k x;k gS\
¼p½ D;k vki dHkh fdlh vijk/k ds fy;s
U;k;ky; }kjk nks’kh Bgjk, x, gaS\
¼N½ D;k vki dHkh fdlh ijh{kk ds fy;s
fooftZr Bgjk, x, ;k fdlh
fo’ofo|ky; ;k fdlh vU;
ftykf/kdj.k@laLFkk }kjk fudkys x;s\
¼t½ D;k vki dHkh fdlh yksd lsok
vk;ksx@deZpkjh p;u vk;ksx }kjk
mldh fdlh ijh{kk esa cSBus@p;u ds
fy, fooftZr@v;ksX; Bgjk, x, gSa\
(a) Have you ever been arrested? gk¡@ugha Yes/No
(b) Have you ever been prosecuted? gk¡@ugha Yes/No
(c) Have you ever been kept under detention? gk¡@ugha Yes/No
(d) Have you ever been bound down? gk¡@ugha Yes/No
(e) Have you ever been fined by a Court of gk¡@ugha Yes/No
Law?
(f) Have you ever been convicted by a Court of gk¡@ugha Yes/No
Law for any offence?
(g) Have you ever been debarred from any gk¡@ugha Yes/No
examination or rusticated by any University or
any other educational authority/institution?
(h) Have you ever been debarred/disqualified gk¡@ugha Yes/No
by any Public Service Commission/Staff
Selection Commission for any of their
examination /selection?

The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 4

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
¼>½ bl lk{;kadu QkeZ dks Hkjrs le;
D;k fdlh U;k;ky; esa vkids fo#)
eqdnek py jgk gSa\
¼¥½ bl lk{;kadu QkeZ dks Hkjrs le;
D;k fdlh ’kSf{kd izkf/kdj.k@laLFkk esa
vkids fo#) dksbZ ekeyk py jgk gSa\
¼V½ D;k ljdkj ds v?khu fdlh izf'k{k.k
laLFkku ds dk;ZeqDr@fu"dkflr@izR;kgr
fd;k x;k vFkok vU;Fkk gSa\
¼B½ mijksDr fdlh Hkh iz’u dk mrj ;fn
gk¡ esa gks rks ekeyk
fxjQrkj@utjcUn@tqekZuk@vijk/kh@
dkjkokl@ltk vkfn ds gksus vkSj@;k
bl QkeZ dks Hkjrs le;
U;k;ky;@fo’ofo|ky;@’kSf{kd
izkf/kdj.k@ laLFkk esa py jgs eqdnes ds
ekeys ds laca/k esa C;kSjk nhft,A
(i) If any case pending against you in any court gk¡@ugha Yes/No
of law at the time of filling up this Attestation
Form?
(j) Is any case pending against you in any gk¡@ugha Yes/No
University or any other educational
authority/institution at the time of filling up
this Attestation Form?
(k) Whether discharged/expelled/withdrawn gk¡@ugha Yes/No
from any training institution under the Govt. or
otherwise?
(l) If the answer to any of the above mentioned gk¡@ugha Yes/No
question is ‘Yes’, give full particulars of the
case/arrest/detention/fine/conviction/sentence/
punishment etc. and/or the name of the case
pending in the Court/University/Educational
Authority etc. at the time of filling up this form.

fVIi.kh% ¼1½ d`i;k lk{;kadu QkeZ ds Åij nh xbZ *psrkouh* dks Hkh nsf[k,A
NOTE: (1) Please also see the “Warning” at the top of this Attestation Form.

¼2½ ;FkkfLFfr *gk¡* ;k *ugh* dks dkV dj izR;sd iz’u dk mrj vyx&vyx fn;k tkuk pkfg,A
(2) Specific answer to each of the question should be given by striking out “Yes” or “No” as the case may be.

13- vius bykds ds nks ftEesnkj O;fDr;ksa ds uke ;k ,sls nks O;fDr;ksa ds uke nhft, tks vkidks tkurs gksAa
Names of two responsible persons of your locality or two referees to whom you are known.

¼v½ (1)_______________________________________________________________________________________________

¼c½ (2) _______________________________________________________________________________________________

eSa izekf.kr djrk@djrh gw¡ fd Åij nh xbZ lwpuk tgka rd eq>s irk gS rFkk fo’okl gS lgh rFkk iw.kZ gSA eSa ,slh fdlh fLFkfr ls
ifjfpr ugha gw¡ ftlds dkj.k esa ljdkj ds v/khu ukSdjh ds fy, ;ksX; u gks ldwaA
I certify that the foregoing information is correct and complete to the best of my knowledge and belief. I am not aware of any
circumstance which might impair my fitness, for employment under Government.

fnukad@Date: ¼mEehnokj ds gLrk{kj½

LFkku@Place: (Signature of Candidate)

The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 5

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
igpku izek.k i=
IDENTITY CERTIFICATE

izek.k i= fuEufyf[kr fdlh ,d ds }kjk gLrk{kfjr fd, tkus ds fy,%

Certificate to be signed by any one of the following:
i) dsUnzh; ;k jkT; ljdkj ds jktif=r vf/kdkjh;
Gazatted Officers of the Central or State Government;
ii) lk/kkj.k rFkk tgka dk mEehnokj rFkk mlds ekrk&firk@j{kd fuoklh gS ml fuokZpu {ks= ds laln ;k jkT; fo/kku
e.My ds lnL;;
Members of Parliament or State Legislature belonging to the constituency where the candidate or his
parent/guardian ordinarily reside;
iii) lc fMfotuy eSftLVsªV vf/kdkjh;
Sub-Divisional Magistrate/Officers
iv) eSftLVsªV dh ’kfDr;ksas dk iz;ksx djus ds fy, Ikzkf/kd`r rglhynkj ;k uk;c mi&rglhynkj;
Tehsildar or Naib/Dy. Tehsildar authorized to exercise magisterial powers;
v) tgka mEehnokj igys i<rk jgk gks ogka ds ekU;rkizkIr Ldwy@dkyst@laLFkk dk fizafliy@eq[;k/;kid;
Principal/Headmaster of the recognized School/College/Institution where the candidate studied last;
vi) Cykd fodkl vf/kdkjh;
Block Development Officers;
vii) iksLVekLVj vkSj
Post Masters; and
viii) iapk;r fujh{kd;
Panchayat Inspectors;

izekf.kr fd;k tkrk gS eSa Jh@Jherh@dqekjh -------------------------------------------------------------------------- iq=@iq=h Jh -----------------------------------------------------------------

dks fiNys ------------- o"kksZ------------- eghuksa ls tkurk gw¡ vkSj tgka rd eq>s irk gS vkSj fo’okl gS fd mlus tks C;kSjs fn;s gSa og lgh gSaA

Certified that I have known Shri/Shrimati/Kumari________________________________________________ Son/

Daughter/Wife of Shri__________________________________________________ for the last _____ years _____
months and that to the best of my knowledge and belief the particulars furnished by him/her are correct.

gLrk{kj@Signature: _________________________
inuke@Designation or: ______________________
vkSj iRkk@Address: __________________________
LFkku@Place:
fnukad@Date:

¼dk;kZy; }kjk Hkjk tkus ds fy,½

(TO BE FILLED IN BY THE OFFICE)

¼1½ fu;qfDr izkf/kdkjh dk uke] inuke rFkk iwjk irk

Director, PGIMER Chandigarh
Name, designation and full address of the appointing authority.

¼2½ in ftlds fy, mEehnokj ds laca/k eSa fopkj fd;k tk jgk gSA
Post for which the candidate is being considered.

The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 6

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

FAMILY DECLARATION FORM – DETAILS OF FAMILY

(to be submitted in duplicate)

Name of the Employee _______________________________________________________

Designation ___________________________ Dept./Section_________________________
Date of Birth ______________________ Date of Joining ____________________________
Details of members of family as on ___________________________

Income from
S. Name of family Date of Relationship
Pension/other Remarks
No. member(s) Birth with employee
sources

I hereby undertake to keep the above particulars up-to date by notifying to the Head of
Office any addition/alteration.

Place: ________________
Date: ________________ (Signature)

Page 1 of 2
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

FAMILY DECLARATION FORM – DEPENDENT

(YEAR: 1ST JANUARY TO 31ST DECEMBER 20____)
(to be submitted in duplicate)

Certified that following member(s) of my family are fully dependent on me:

S.No. Name Age Relation Income Address

Place: ________________
Date: ________________ (Signature)

Page 2 of 2
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

HOME TOWN DECLARATION FORM

(to be submitted in duplicate)

I, ____________________________________________________________ hereby
declare that my home town is at the place as shown below for the purpose of availing
myself of the Leave Travel Concession as notified in the Govt. of India, Ministry of
Home Affairs, New Delhi OM No.43/1/55/Estts-(A) Part-II dated 11-01-1956:

Village

Post Office

City

District
with Pin
Code

State

Nearest
Railway
Station

Place: ________________
Date: ________________ (Signature)
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

MARITAL DECLARATION
(to be submitted in duplicate)

I, ___________________________________________________ declare as under:

*(i) That I am unmarried / a widower / a widow.

*(ii) That I am married and have only one spouse living.
*(ii) That I have entered into or contracted a marriage with a person having a
spouse living. Application for grant of exemption is enclosed.
*(iv) That I have entered into and contracted a marriage with another person
during the lifetime of my spouse. Application for grant of exemption is enclosed.

I solemnly affirm that the above declaration is true and I understand that in the
event of the declaration being found to be incorrect after my appointment, I shall be
liable to be dismissed from service.

Place: ________________
Date: ________________ (Signature)

* Strikeout whichever is not applicable.

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

OATH OF ALLEGIANCE
(to be submitted in duplicate)

I _________________________________, do swear in the name of God/solemnly

affirm that I will bear true faith and allegiance to the Constitution of India as by law
established, that I will uphold the sovereignty and integrity of India, that I will duly
and faithfully and to the best of my ability, knowledge and judgment perform the
duties of my office loyally, honestly, with impartiality and without fear or favour,
affection or ill-will and that I will uphold the Constitution and the laws.

(So help me God)

Place: ________________
Date: ________________ (Signature)

I certify that the oath of allegiance was taken in my presence.

Signature of the Certifying Officer

 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

OATH OF SECRECY
(to be submitted in duplicate)

I______________________________________________________________ have
been appointed as __________________________________________________ at
PGIMER Chandigarh, do swear in the name of God/solemnly affirm that I will bear
true faith and allegiance to the Official Secrets Act, 1923, Central Civil Services
(Conduct) Rules, 1964, Central Civil Services (CCA) Rules, 1965, PGIMER Act, Rules,
Regulations, and that I will discharge and perform the duties of my office to the best
of my ability, knowledge and judgment, without fear or favour, affection or ill will,
and that I will not directly or indirectly communicate of reveal to any matter which
shall be brought under my consideration.

Place: ________________
Date: ________________ (Signature)
Annexure S1 Page 1

Application for Allotment of Permanent Retirement Account Number (PRAN)

(To avoid mistake(s), please follow the accompanying instructions and examples carefully before filling up the form)
To affix recent
Acknowledgement No. Coloured photograph
(To be filled by FC) (3.5 cm × 2.5 cm)

Permanent Retirement Account Number :

(To be filled by FC after PRAN generation )

Sir/Madam,

I hereby request that a permanent retirement account number be allotted to me.

I give below necessary particulars :

Signature/Left Thumb Impression
Section A - Subscribers Personal Details ( * Indicates Mandatory Field) of Subscriber in black ink
1. Full Name (Full expanded name: initials are not permitted)
Please Tick as applicable, Shri Smt . Kumari
First Name *

Middle Name

Last Name

2. Gender * Please Tick as applicable, Male Female

3. Date of Birth * 4. PAN

D D M M Y Y Y Y (Date of Birth to be Certified by DDO)

5. Father’s Full Name:
First Name *

Middle Name

Last Name

6. Present Address:
Flat/Unit No, Block no. *

Name of Premise/Building/Village

Area/Locality/Taluka

District/Town/City *

State / Union Territory *

Country *

Pin Code *

7. Permanent Address: If same as above, Please Tick else,

Flat/Unit No, Block no. *

Name of Premise/Building/Village

Area/Locality/Taluka

District/Town/City *

State / Union Territory *

Country *

Pin Code *

8. Phone No.
STD Code Phone No.

9. Mobile No.
Version 1.2
 Annexure S1 Page 2
10. Email ID

11. Subscribers Bank Details : (Please refer instruction no. 4) Savings A/c Current A/c

Bank A/c Number*

Bank Name*

Bank Branch*

Bank Address*

Pin Code*

Bank IFS Code (If IFS code is not available, then provide MICR)

Bank MICR Code

Declaration by subscriber for Bank details: At present, I do not have a Bank account. However, I confirm to provide the requisite Bank
account details within six months or on opening of Bank account whichever is earlier to the associated nodal office for updating the same in CRA system.
(Please tick (√) in case, Bank details are not available)
12. Value Added Services: i) SMS Alert Yes No

ii) Email Alert: Yes No

I _____________________________________________________________ , the applicant, do hereby declare that

what is stated above is true to the best of my information & belief.

Date :

D D M M Y Y Y Y Signature/Left Thumb
Impression of Subscriber
Section B - Subscribers Employment Details to be filled and attested by DDO (All Details are Mandatory)
1. Date of Joining 2. Date of Retirement

D D M M Y Y Y Y D D M M Y Y Y Y

3. PPAN (Please refer to instructions No.5.)

4. Group of the Employee (Please Tick) Group A Group B Group C Group D

5. Office

6. Department

7. Ministry

8. DDO Registration Number 9. PAO/CDDO Registration Number (Please refer to

instructions No.6.)
10. Basic Salary
11. Pay Scale

Certified that the above declaration has been signed / thumb impressed before me by ________________________________________________________________
after he / she has read the entries / entries have been read over to him / her by me and got confirmed by him / her. Also certified that the date of birth and employment
details is as per employee records available with the Department.

Signature of the Authorised Person

Rubber Stamp of the DDO
Designation of the Authorised Person : _________________________________
Name of the DDO ______________________
Date :

D D M M Y Y Y Y Department / Ministry _______________________

Version 1.2
 Annexure S1 Page 3

Section C - Subscriber’s Nomination Details (* Indicates Mandatory Field for nominee)

1. Name of the Nominee *:
1st Nominee 2nd Nominee 3rd Nominee
First Name * First Name * First Name *

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

2. Date of Birth (In case of a minor)*:

1st Nominee 2nd Nominee 3rd Nominee

3. Relationship with the Nominee*:

1st Nominee 2nd Nominee 3rd Nominee

4. Percentage Share *:
1st Nominee % 2nd Nominee % 3rd Nominee %

5. Nominee’s Guardian Details (in case of a minor)*:

1st Nominee’s Guardian Details 2nd Nominee’s Guardian Details 3rd Nominee’s Guardian Details
First Name * First Name * First Name *

Middle Name Middle Name Middle Name

Last Name Last Name Last Name

6. Conditions rendering nomination invalid:

1st Nominee 2nd Nominee 3rd Nominee

Section D - Subscriber Scheme Details

1st Scheme 2nd Scheme 3rd Scheme
Pension Fund Managers Name/Code Pension Fund Managers Name/Code Pension Fund Managers Name/Code

Scheme ID No./Name Scheme ID No./Name Scheme ID No./Name

Percentage Share Percentage Share Percentage Share

% % %

Section E - Declaration

I understand that there would be PFRDA approved Terms and Conditions for Subscribers on the CRA website governing I-
Pin (to access CRA / NPSCAN and view details) & T-pin. I agree to be bound by the said terms and conditions and understand
that CRA may, as approved by PFRDA, amend any of the services completely or partially without any new
Declaration/Undertaking being signed.

I _________________________________________________________________ , the applicant, do hereby declare that

what is stated above is true to the best of my information & belief.

Date :
D D M M Y Y Y Y
Signature/Left Thumb
Impression of Subscriber

Version 1.2
Annexure S1 Page 4

INSTRUCTIONS FOR FILLING PRAN FORM

a) Form to be filled legibly in BLOCK LETTERS and in BLACK INK only.

b) Details Marked with (*) are the mandatory fields.
c) Each box, wherever provided, should contain only one character (alphabet/number/punctuation mark) leaving a blank box after each word.
d) 'Individual' Subscriber should affix a recent colour photograph (size 3.5 cm x 2.5 cm) in the space provided on the form. The photograph should not
be stapled or clipped to the form. (The clarity of image on PRAN card will depend on the quality and clarity of photograph affixed on the form.)
e) Signature /Left thumb impression should only be within the box provided in the form. The signature should not be on the photograph. If there is any
mark on the photograph such that it hinders the clear visibility of the face of the Subscriber, the application will not be accepted.
f) Thumb impression, if used, should be attested by a Magistrate or a Notary Public or a Gazetted Officer under official seal and stamp.

Sr.
Item No Item Details Guidelines for Filling the Form
No.
Section A - Subscribers Personal Details
1 3. Date of Birth All Dates Should be in “DDMMYYYY” Format
2 6. Present Address All future communications will be sent to present address.
Phone No., Mobile No, It is advisable to mention either “Telephone number” or “Mobile number” or “Email
3 8, 9, 10
& Email ID id” so that Subscriber can be contacted in future for any discrepancy.
For subscribers, the Bank details are mandatory. In case, Bank details are not
Subscriber’s Bank available at the time of filling the form, subscriber has to accept the declaration for
4 11
Details providing the Bank details within six months or on opening of Bank account
whichever is earlier.
Section B - Subscribers Employment Details
It is mandatory to fill the Subscriber’s Employment details in the application. The employment details should be filled by the respective DDO of the
Subscriber and should be verified by the Authorised Signatory.
DDO should ratify Overwriting / Striking off of any of the employment details.
Kindly provide the PPAN (Permanent Pension Account Number), if it has been
5 3. PPAN
allotted to the subscriber by the concerned PAO.
PAO/CDDO Reg. No. and DDO Reg. No. are the unique Registration number
allotted by Central Recordkeeping Agency.
PAO/CDDO Reg. No.
6 8&9 CDDOs will register as both PAOs and DDOs.
& DDO Reg. No.
NCDDOs will register only as DDOs and obtain the PAO Reg. No. from their
respective PAOs.
Section C - Subscriber’s Nomination Details
Subscriber can nominate maximum of three nominees.
Subscriber can not fill the same nominee details more than once.
Percentage share value for all the nominees must be integer. Fractional value will not
7 4. Percentage Share
be accepted.
Sum of percentage share across all the nominees must be equal to 100. If sum of
percentage is not equal to 100, entire nomination will be rejected.
Nominee’s Guardian
8 5. If a nominee is a minor, then nominee’s guardian details will be mandatory.
Details
Section D - Subscriber scheme details

If the Subscriber is unable to mention the Scheme details i.e. PFM Name, Scheme Name & Percentage Allocation he can contact the nearest
Facilitation Centre (FC) for information or the Subscriber can also search for the scheme details on http://www.npscra.nsdl.co.in
Subscriber can select maximum three schemes. Details of the schemes are available on
http://www.npscra.nsdl.co.in
Subscriber can not fill the same scheme details more than once.
9 Scheme
If a scheme name is filled in the form for scheme setup there must be a PFM name and percentage contribution
filled for that scheme.
If the Scheme details are not filled, default scheme as approved by PFRDA will be applicable
Scheme Contribution Value will be in terms of percentage. It cannot be in terms of amount.
Percentage contribution value for all the schemes must be integer. Fractional value will not be accepted.
10 Percentage Share
If the sum of contributions (in percentage) across all the schemes is not equal to 100, the balance will be allotted
to the default scheme approved by PFRDA.

GENERAL INFORMATION FOR PRAN SUBSCRIBERS

a) Subscribers can obtain the application form for PRAN in the format prescribed by PFRDA (Pension Fund Regulatory & Development Authority)
from DDO or can freely download from the CRA website (http://www.npscra.nsdl.co.in ).
b) The request for a reprint of PRAN card with the same PRAN details or/and changes or correction in PRAN data can be made by filling up
'Request for change/correction in subscriber master details and/or re-issue of I-Pin/T-Pin/PRAN card’ or/and ‘Request For change in
signature and/or change in photograph’. The form is available from the sources mentioned in (a) above.
c) The Subscriber can obtain the status of his/her application from the CRA website or through the respective PAO/CDDO.
d) For more information
Visit us at http://www.npscra.nsdl.co.in
Call us at 022-24994200
e-mail us at info.cra@nsdl.co.in
Write to: Central Recordkeeping Agency, NSDL e-Governance Infrastructure Limited, 1st Floor, Times Tower, Kamala Mills
Compound, Senapati Bapat Marg, Lower Parel (W), Mumbai - 400 013.

Version 1.2
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

FORM 1
OPTION TO AVAIL BENEFITS IN CASE OF DEATH OR DISCHARGE ON INVALIDATION
OR DISABILITY OF GOVERNMENT SERVANT / SUBSCRIBER DURING SERVICE
[See rule 10)

* I, _____________________________________________________________, hereby
exercise option that in the event of my discharge from service on the account of disability or
retirement from service on account of invalidation or Death during service, benefits under
CCS (Pension) Rules, 1972 or CCS (Extraordinary Pension) Rules, 1939 as the case may be,
may be paid to me or my family.

OR

* I, _____________________________________________________________, hereby
exercise option that in the event of my discharge from service on the account of disability or
retirement from service on account of invalidation or Death during service, benefits may be
paid to me or my family, as the case may be, based on the accumulated pension corpus in
the Individual Pension Account under the National Pension System in accordance with the
CCS (Implementation of National Pension System) Rules, 2021.

Place: ________________
Date: ________________ (Signature)

* Completely strike out the benefits for which option is not intended to be made.

(To be filled in by the Head of Office or authorised Gazetted Officer)

Received the option dated _____________, under CCS (Implementation of National Pension
System) Rules, 2021 made by Shri/Smt./Kumari___________________________________,
Designation_____________________________________________.

Entry of receipt of option has been made in page ______ Volume _____ of Service Book.

Signature
Name and Designation of Head of Office or
authorized Gazetted Officer with seal
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

NOMINATION FOR BENEFITS UNDER THE CENTRAL GOVENRMENT EMPLOYEES

GROUP INSURANCE SCHEME, 1980
(to be submitted in duplicate)

When the Government servant has family and wishes to

nominate one member or more than one member, thereof

I, ________________________________________________________ hereby nominate

the person(s) mentioned below who is/are member(s) of my family, and confer on him/them
the right to receive, to the extent specified below any amount that may be sanctioned by the
Central Government under the Central Government Employees Group Insurance Scheme,
1980 in the event of my death while in service of which having become payable on my
attaining the age of superannuation may remain unpaid at my death:

Name, address, relationship

* Share of Contingencies on the of persons, if any, to whom
Relationship
Name and addresses amount happening of which the right of the nominee
with the Govt. Age
of nominee/nominees to be paid the nomination shall shall pass in the event of the
Servant
to each become invalid nominee predeceasing the
Government Servant

NE: The Government servant should draw line across the blank space below his last entry to prevent insertion of
any name after he has signed.

Place: ________________
Date: ________________ (Signature)

* This column should be filled in as to cover the whole amount that may be payable under the Insurance
Scheme.
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

LEGAL UNDERTAKING

I, ____________________________________ S/o/D/o ______________________,

resident of _____________________________________________ appointed to the
post of ___________________________________________ in PGIMER Chandigarh
do hereby undertake and declare that I have not filed any court case or any legal
proceedings against PGIMER Chandigarh nor any case or legal proceedings whether
civil or criminal or any disciplinary proceedings are pending against me before any
court / tribunal / forum anywhere in India.

The offer of appointment shall be subject to the outcome of any criminal court
cases/legal proceeding pending anywhere in India and before any court or Tribunal
affecting/pertaining to such appointment in PGIMER Chandigarh. In case any such
case/legal proceeding is detected or reported in future or any material facts are
suppressed by me including legal/quasi legal proceeding of any nature pertaining to
such appointment in PGIMER Chandigarh, my services are liable to be terminated
summarily without assigning any reason and the same shall be binding on me.

The above statement is made to the best of my knowledge and belief. I further agree
and undertake that in case it is found at any point of time that the above declaration
/ undertaking is false or incorrect in any way or manner then my appointment in
PGIMER Chandigarh is liable to be cancelled/ terminated summarily without assigning
any reason, for which I shall be held entirely liable and the same shall be binding on
me. Further, in such an event, PGIMER Chandigarh shall be at liberty to forfeit my
dues and recover appropriate damages from me for which I agree to be liable to pay.

Place: ________________
Date: ________________ (Signature)
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

Ref. No.____________ Date: ______________

FORM No. I
STATEMENT OF IMMOVABLE PROPERTY FOR THE YEAR __________
(as on 31st December)

1. Name of the employee ________________________________________

2. Designation ________________________________________

3. Total length of service in PGIMER ________________________________________

Chandigarh (till date)

4. Present pay (Basic) ________________________________________

5. Name of the district, sub-division, ________________________________________

Taluka and Village in which property is
situated. ________________________________________

6. Name & details of property (Housing, ________________________________________

Land, other buildings etc.)
________________________________________

7. Present value `_______________________________________

8. If not in own name, state in whose ________________________________________

name held and his/her relationship
with the employee ________________________________________

9. How the property is acquired? ________________________________________

Whether by lease, mortgage,
inheritance, gift or otherwise, with ________________________________________
date of acquisition and name with
details of person / persons from whom ________________________________________
acquired

10. Annual income from property `_______________________________________

11. Remarks ________________________________________

________________________________________

________________________________________

DECLARATION

I, hereby declare that the above information (from 1 to 11) is complete, true and correct as on 31-12-
________, to the best of my knowledge and belief, in respect of information due to be furnished by me
under the provisions of Sub-rule (1) of Rule 18 of Central Services (Conduct) Rules, 1964.

Date : _____/_____/20____ Signature: _______________________

Page | 1
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

FORM No. II
Statement of liquid assets on first appointment (recruited in 20___ calendar year)

(1) Cash and Bank balance exceeding 3 months' emoluments.

(2) Deposits, loans, advances and investments (such as shares, securities, debentures etc.
If not in own name, name and
Name and address address of person in whose Annual
Sl.
Description of Company, Bank Amount name held and his/her Income Remarks
No.
etc. relationship with the PGIMER derived
employee
1 2 3 4 5 6 7

Note :

1. In column 7, particulars regarding sanctions obtained or report made in respect of the various transactions may
be given.
2. The term "emoluments" means the pay and allowances received by the PGIMER employee.

FORM No. III

Statement of movable property on first appointment (recruited in 20___ calendar year)
Price or value at the time of
If not in own name, name How acquired
acquisition and/or the total payments
and address of the person with
Sl. Description made up to the date of return, as the
in whose name and his/her approximate Remarks
No. of items case may be in case of articles
relationship with the date of
purchased on hire purchase or
PGIMER employee acquisition
installment basis
1 2 3 4 5 6

Date : _____/_____/20____ Signature: _______________________

Note :

1. In this Form, information may be given regarding items like (a) jewellery owned by him (total
value); (b) silver and other precious metals and precious stones owned by him not forming part of
jewellery (total value); (c) (i) Motor Cars, (ii) Scooters / Motor Cycles, (iii) refrigerators / Air
conditioners, (iv) radios / radiograms / television sets and any other articles, the value of which
individually exceeds `1,000; (d) value of items of movable property individually worth less than
`1,000 other than articles of daily use such as clothes, utensils, books, crockery, etc., added
together as lump sum.
2. In Column 5, may be indicated whether the property was acquired by purchase, inheritance, gift or
otherwise.
3. In Column 6, particulars regarding sanction obtained or report made in respect of various
transactions may be given.

Page | 2
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

FORM No. IV
Statement of Provident Fund and Life Insurance Policy on First Appointment (recruited in 20___ calendar year)

Insurance Policies
Sl. Policy No. and Name of Insurance Amount of
Sum insured / date of maturity
No. date of Policy Company annual premium
1 2 3 4 5

Provident Fund
Closing balance as last Remarks (if there is dispute
Type of Provident reported by the Contribution regarding closing balance, the
Funds/GPF/CPF/ Audit/Accounts officer made Total figures according to the PGIMER
NPS Account No. along with date of such subsequently employee should also be
balance mentioned in this column)
6 7 8 9 10

FORM No. V
Statement of Debts and Other Liabilities on First Appointment (recruited in 20___ calendar year)
Date of
Sl. Name and address of Details of
Amount incurring Remarks
No. Creditor Transaction
Liability
1 2 3 4 5 6

Date : _____/_____/20____ Signature: _______________________

NOTE :

1. Individual items of loans not exceeding three months emoluments or `1,000 whichever is less, need
not be included.
2. In column 6, information regarding permission, if any, obtained from or report made to the
competent authority may also be given.
3. The term "emoluments" means pay and allowances received by the PGIMER employee.
4. The Statement should also include various loans and advances available to Government servants like
advance for purchase of conveyance, house building advance, etc. (other than advances of pay and
traveling allowance, advances from the GP Fund and loans on Life Insurance Policies and fixed
deposits).

Page | 3
 THROUGH PROPER CHANNEL
To

The Financial Adviser,

Postgraduate Institute of Medical
Education & Research, Chandigarh.

Subject: Grant of Transport Allowance (Central Pay Scale).

Respected Sir,
with reference to office order Endst. No. PG/1998/30596-691, dated
PG/MA/2000/19831-914, dated 20.04.2000, on the subject noted above, I am to certify as under:
26.09.1998 and

That I am working as . in the Deptt. of PGIMER,

Chandigarh since & getting Basic Pay of according to 6 Central pay scale.

That I am residing at House No Sector/Phase Chandigarh/PKL/ Mohali

since
That I have not been provided free transport facility by the PGI during the period to
_date (Certificate from Transport Office enclosed).
30 days due to tour etc. during the
from duty for the period exceeding
That I have not remain absent
2000 except for the period from_
to
period August 1997 to April
the Government of
be granted Transport Allowance
sanctioned by
In view of the above, I may kindly October-1997.
Department of vide O.M. No. 21(1) 97/EW(B), dated 3
India, Ministry of Finance,

Thanking you.

Yours faithfully,

Name:
Designation: -_
Emp. Code No_

Deptt.
action.
Forwarded to the Financial Adviser, PGIMER, Chandigarh for necessary

HEAD OF THE DEPTT.

Certified by Transport Department

has availed/not

Certified that Mr./Ms_

since to
availed/Not availing PGI staff Bus facility

(Vehicles),
Sr. Technical Officer
Transport Deptt.
PGIMER, Chandigarh.
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

SERVICE BOOK OF
EMPLOYEE PERSONAL INFORMATION
SECTION-1
Employee Code Old Employee Code File/Service Book No.
Employee Name Gender Date of Birth
Place of Birth Height Weight
Physical Mark Marital Status Blood Group
Caste Religion Nationality
Mother Tongue Minority Community
SECTION-2
Percentage of Type of Differently
Is Differently abled
Differently abled abled
LANGUAGE KNOWN
Language Known Read Write Speak
Hindi
English
OFFICIAL DETAILS
CPF/GPF Number PAN Number
Passport Number LIC Policy Number
Bank Account No.
CONTACT DETAILS
Current Address Details
House No. Locality City
District State Pin Code
Country
Permanent Address Details
House No. Locality City
District State Pin Code
Country
Home Town Details
Town City District
Nearest Railway
State Thana
Station
Contact Details
Telephone No. Mobile No. Office Ext.
FAX No. Email Id
PARENTS AND SPOUSE DETAILS
Father’s Name Mother’s Name
Spouse Name Spouse Nationality
Is Spouse Working Spouse Occupation
Family Income
FAMILY AND NOMINATION DETAILS
Family Member
Year of Birth Birth Place
Name
Sex Relation Marital Status
Dependent
Is Dependent Dependent Upto
Occupation Details
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration

Family Member
Year of Birth Birth Place
Name
Sex Relation Marital Status
Dependent
Is Dependent Dependent Upto
Occupation Details
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration

Family Member
Year of Birth Birth Place
Name
Sex Relation Marital Status
Dependent
Is Dependent Dependent Upto
Occupation Details
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

Dependent Present Address

GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration

Family Member
Year of Birth Birth Place
Name
Sex Relation Marital Status
Dependent
Is Dependent Dependent Upto
Occupation Details
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration

Family Member
Year of Birth Birth Place
Name
Sex Relation Marital Status
Dependent
Is Dependent Dependent Upto
Occupation Details
Dependent Present
Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration
EMPLOYEE CURRENT JOB DETAILS
Employee Office Work Location Post Graduate Institute of Medical Education and Research, Chandigarh
Employee Class Nature of Job From Date
Source of
To Date Service Group
Recruitment
Cadre Appointment Date Joining Date
Retirement Date Designation Department
Pay Scale Category Pay Scale Type
Pay Band Pay Scale Grade Pay
Pay Scale Effective
Basic Pay Basic Effective Date
Date
Consolidated Salary
Consolidated Salary Seniority No.
Effective Date
Seniority Date Next increment Date Current Status
QUALIFICATION DETAILS
Examination
Serial No. University/Board Subject Year of Passing Percentage%
Degree
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

FILLED IN CAPITAL LETTERS – ALL INFORMATION IS MANDATORY

Name of the Employee _______________________________________________

Designation & Dept. _______________________________________________

Date of Joining _______________________________________________

Category (Gen/SC/ST/OBC/EWS) _______________________________________________

Father’s Name _______________________________________________

Gender (Male/Female) _______________________________________________

Nationality _______________________________________________

State to which belongs _______________________________________________

Permanent address & postal _______________________________________________

address with pin code _______________________________________________
_______________________________________________

Qualification _______________________________________________

Name of Institute from which _______________________________________________

MD/MS/Ph.D. passed year and
month of passing

Medical Registration no./Year _______________________________________________

Experience Period & Name of the _______________________________________________

Institute

Current Mobile No. _______________________________________________

SBI A/C No. _______________________________________________

(attached 2 photo copies)

PAN _______________________________________________
(attached 2 photo copies)
 LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGAR

JOINT DECLARATION

I_______________________________ employed as ___________________________ in

____________________________ and __________________________________ (Name
of Spouse) employed as _____________________________________ (Designation &
Organization) hereby jointly declare that all medical facilities (OPD as well as
Indoor) in respect of our family and dependents will be preferred by _________________
only (Name of employee/spouse who is to prefer the medical facilities).

It is also jointly declared that Sh./Smt./Dr._____________________________________

(Name of the employee/spouse not preferring medical facilities) is not in receipt of any
medical facilities or financial/medical allowance in lieu thereof either for self and/or
members of the family from _______________________________________ (Name of
the organization).

Signature__________________________
(Employee)
Name_____________________________
Complete Address___________________
__________________________________
Signature__________________________
(Spouse)
Name_____________________________
Complete Address___________________
__________________________________

Certificate to be provided by the Drawing & Disbursing Officer/any other

competent authority of the organization where spouse is working:

It is certified that Sh./Smt./Dr._________________________________________

S/o,D/o,W/o,H/o________________________________is employed in the organization
as ____________________. He/She is not in receipt of any medical facility or any
financial/or any medical fixed allowance in lieu thereof either for self and member(s) of
the family from______________________________________.

Fixed Medical allowance stopped w.e.f :____________________.

Signature of Competent Authority

Name of Officer________________________
Designation___________________________
 Affix passport size
group photo

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION

& RESEARCH, CHANDIGARH
Registration Performa for New registration/addition/deletion of family dependent (s) names with staff clinic.
1. Name of the Official/Date of Birth __________________________________________________
2. Son/Daughter/Wife of __________________________________________________
3. Designation __________________________________________________
4. Department __________________________________________________
5. Permanent home address __________________________________________________
6. Contact Phone/Mobile No __________________________________________________
7. Date of joining the institute __________________________________________________
8. Employee Code No. __________________________________________________
9. Did you get any registration number
Earlier if so, please quote the same __________________________________________________
10. In case of Senior Residents
(a) Are you a sponsored candidate? __________________________________________________
(b) Tenure of present appointment/Deputation From_______________ To____________________
11. Whether Regular/Adhoc or on Deputation_______________________________________________
12. If Retired Please Quote PPO No. ____________________________________________________
13. List of family dependents members & other Particulars as shown in the below table should be filled up with
great care.
Sr.No. Name of the dependent(s) Date of Sex Relationship Occupation/Income/
members Birth/Age Retd/Pvt.Business

14. Name (s) of the family dependent(s) members whom you intend for deletion. His/her name with must be
mentioned in the below table:
Sr.No Name of the dependent(s) members Reasons for deletion of his/her Name (s) in the staff clinic

Signature Signature of the candidate

Head of Department
With Seal.
 INSTRUCTIONS FOR APPLICANT FOR DECLARING THE FAMILY MEMBERS FOR WHOM
TREATMENT CAN BE AVAILED IN P.G.I. AS DEPENDANT.

General: - The term ‘Family’ for the purpose of Central Services (Medical Attendances) Rules 1944 shall
mean a Government Servant’s wife or husband as the case may be and parents, sister, widowed daughters,
widowed sisters minor brothers, children and step children wholly dependent upon the govt. servant.
Note: The members of the family are treated as dependent only, if their income from all sources including
pension and equivalent gratuity does not exceed Rs. 9000/- P.M. The condition of dependency both in the
case of the husband or the wife of the Govt. Servant has been dispensed with.
Age limits of Dependent/Son /Daughter:-
i) Son Till he starts earning or gets married or till the age of 25 yrs
whichever is earlier.
ii) Daughter/Sister Till starts earning or gets married whichever is earlier
irrespective of age limit.
When both (husband/wife) are Central Govt. servants: - In case where both husband and wife are govt.
servants then they as well as eligible dependents may be allowed to avail of the medical concessions
according to his or her status. For this purpose they should furnish a joint declaration as to who will prefer
the claim for reimbursement of medical expenses incurred.
 The above declaration should be submitted in duplicate and a copy of each shall be recorded in the
personal file of them in their respective offices.
 The declaration shall remain in force till such time as it is revised on the event of
promotion/transfer/resignation etc. of either or the two. In case, the spouse is stationed at different station
then they can avail medical facilities for only the members who are residing with her/him.
When the spouse is governed by different medical rules, stationed at different station: - In case of govt.
servants covered under CS (MA) rules 1944, and whose spouses are employed in other organizations
providing different medical facilities, the govt. servant concerned can avail medical facilities under CS (MA)
rules, 1944 in respect of him/her as the case may be provided:
a) His/her spouse employed in other organizations is not in receipt of fixed monthly medical
allowance.
b) He/she produces a certificate from the employer of his/her spouse that he/she is not claiming
medical facilities in respect of his/her spouse and their family members.
Dependency of Parents:-
 The declaration regarding the income and residence of parents is submitted every year.
 Recurring monthly income from sources such as house/land holding investments/share etc. shall be taken
into account for the purpose of monthly income.
 The information supplied by an official/officer is subject to verification by independent agency and if
found false will render the applicant liable for disciplinary action for misutilization of services by giving
wrong information.
List of Enclosures:-
1. Attested Photocopy of appointment letter.
2. Birth Certificate of all Children/Brother/Sister (if dependent).
3. Joint declaration if spouse is employed.
4. Income Certificate from Competent Authority of Revenue Department of the place of
residence of parents/ in laws in original regarding income.
5. Two attested passport size photographs. (one Photo to be pasted and second to be
attached)
6. Pension papers (if retired).
Self-Declaration:- Verified that I have gone through the above instructions carefully and if found false will
render to be liable for any disciplinary action for misutilization of services by me giving wrong
information/declaration in the staff clinic, PGIMER. I further solemnly affirm and declare that the contents
stated above are true to the best of my knowledge and belief and neither part of it is false nor anything has
been concealed therein.

Signature of the applicant

Note: - Please inform Staff Clinic Office as and when there is change in status of dependent beneficiaries.

*Form can be downloaded at PGI Web Portal pgimer.edu.in.

 Affidavit

(for dependency of parents for medical facilities)

I, …………………………………………………. S/o/W/o…………………………………………….… and

resident of ……………………………………………………………………………. do hereby solemnly

affirm and declare as under:

1. That I am working in Post-graduate Institute of Medical education and

Research (PGIMER), Chandigarh and at present designated as

……………………………………………….

2. That I certify that total monthly income of my father/mother/father-in-

law/mother-in-law (delete which is not applicable)

namely…………………………………………………………………………… from all sources

including pension/family pension and pension equivalent to DCRG (death cum

retirement gratuity) is less than ‘₹ 9000/- (Rupees Nine Thousand only) plus

the amount of dearness relief on basic pension of ₹ 9000/- (Rupees Nine

Thousand only) as on the date of consideration (as applicable today)’.

I have taken into consideration all sources of recurring income viz. income

from rented property, interest earned from bank deposits, dividend income,

returns from security etc., agricultural income and any other

regular/recurrent income.

Further, for reckoning the income, the pension originally sanctioned has been

taken into account for determining the entitlement and not the pension after

commutation.

3. I certify that my father/mother/father-in-law/mother-in-law (delete which is

not applicable) is/are not getting medical facilities in any form including fixed

medical allowance from any other source.

I understand that the benefit of medical facilities/medical reimbursement

cannot be claimed from two different sources. In this regard, I declare that

no medical facility/medical reimbursement for my father/mother/father-in-

law/mother-in-law (delete which is not applicable) is claimed or availed by

any of my siblings.
 4. I understand that if there is any change in any of the depositions made

above, I shall immediately inform PGIMER, Chandigarh about such change,

failing which appropriate action may be taken against me.

5. The above information furnished by me is correct and complete and no

information has been concealed or misrepresented. I am aware that in the

event of any statement/information furnished above is found to be

false/wrong/incomplete/misleading at any stage, I will be liable to return the

whole amount of medical expenditure availed/claimed along with interest in

addition to the disciplinary action against me in accordance with CCS

(Conduct) Rules, 1964 or/and any other applicable rule.

6. I understand and agree that above information furnished by me can be got

verified by PGIMER, Chandigarh from any authorized agency at any stage.

Deponent

Date:

Verification:

Verified on ……………………………………………. that the above contents of the

aforesaid affidavit are true and correct and nothing material has been concealed

therein and that any change in the above context shall be immediately intimated by

me to the PGIMER, Chandigarh.

Deponent
 CHARACTER CERTIFICATE

Certified that I have known Shri/Smt./Dr.______________________________

S/o/D/o. Shri/Smt./Dr. _____________________________ for the last ______
years ______ months and that to the best of my knowledge and belief he/she bears
reputable character and has no antecedents which render him/her unsuitable for
employment under Government of India.

Shri/Smt./Dr.___________________________________ is not related to me.

Place: ________________
Date: ________________ (Signature & Stamp of
Gazetted Officer)