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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
________________________________________ 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. The
following documents checked and verified from the originals:
1.________________________________ 2. ______________________________
3.________________________________ 4. ______________________________
5.________________________________ 6. ______________________________
7.________________________________ 8. ______________________________
9.________________________________ 10. _____________________________
11._______________________________ 12. _____________________________
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
The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 1
mEehnokj }kjk viuh fy[kkoV esa gh Hkjk tkuk pkfg;sA
To be filled in by the candidate in his own handwriting.
lk{;kadu QkeZ@ATTESTATION FORM
psrkouh@WARNING
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
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).
miuke@Surname uke@Name
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
gky gh ds ikliksVZ vkdkj
¼3-5 ls-eh- x 4-5 ls-eh-½ ds
gLRkk{kfjr QksVks dh izfr
fpidkb,
Affix singed Passport
size (3.5 cm x 4.5 cm
approx.) copy of recent
photograph
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 2
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
ftyk ;k edku u-] xyh@lM+d@ekxZ vkSj uxj½
Residential address in full (i.e.), Village, Thana & Distt. or
House No/ Lane/Street/ Road & Town
fiNys [kkus esa fn;s x;s LFkku ds
ftys ds eq[;ky; dk uke
Name of the Dist. H.O. of the place
mentioned in the preceding column
dc ls@From dc rd@To
5- ¼d½ (a)
fj'rk uke
Relation Name
jk"Vªh;rk ¼tUe ls
vkSj@;k vf/kokl ls½
Nationality (by
birth and/or
by domicile)
tUe dk LFkku
Place of birth
O;olk; ¼;fn lsok esa
gks rks iwjk inuke
vkSj dk;kZy; dk iwjk
irk fn;k tk;s½
Occupation (if
employed give full
designation &
Official address)
orZeku Mkd dk irk
¼;fn e`rd gks rks
fiNyk irk½
Present Postal
address (if dead
give last address)
?kj dk LFkkbZ irk
Permanent
Home 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)
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 3
¼[k½ fons’k esa i<+ jgs@jg jgs iq= ¼iq=ksa½ vkSj@;k iq=h ¼iqf=;ksaa½ 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.
uke Name
jk"Vªh;rk ¼tUe ls
vkSj@;k vf/kokl ls½
Nationality (by
birth and/or by
domicile)
tUe dk LFkku
Place of birth
ns'k dk uke tgka i<+
jgs@jg jgs gSa iwjk irk
Country in which
studying/ living with
full address
fiNys dkye esa fn;s x;s ns'k esa
ftl rkjh[k ls jgs gS
Date from which
studying/living in the country
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;@vuqlwfpr tkfr@ vuqlwfpr tutkfr@
vU; fiNM+k oxZ½@Category (UR/SC/ST/OBC)
(iv)
(v) fodykaxrk ¼vks-,p-@,p-,p-@oh-,p-½@
Person with Disability (OH/HH/VH)
(v)
(vi) /keZ@Religion (vi)
8. O;fDrxr igpku dh fu'kkuh
Personal Marks of identification
(i)
(ii)
9. (i) tUe LFkku] ftyk vkSj jkT; ftlesa ;g fLFkr gS
Place of birth, Distt & State in which situated
(i)
(ii) vki fdl ftys vkSj jkT; ds gS
Distt. & State to which you belong
(ii)
(iii) vkids firk ewy #i ls fdl ftys vkSj jkT; ds gS
Distt. & State to which your father belongs
(iii)
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
Educational qualifications showing places of education with years in Schools and College since the 15
th
Year age.
Ldwy@dkyst dk uke vkSj iwjk irk
Name of School/College with full address
izos'k dh rkjh[k
Date of entering
NksM+us dh rkjh[k
Date of Leaving
ijh{kk mrhZ.k dh
Examination Passed
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 4
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
Lo#i
Designation, emoluments and
nature of employment
fu;ksDrk dk iwjk uke o iRkk
Full name and address of employer
igyh ukSdjh NksM+us dk
dkj.k
Reasons of leaving
previous service
dc ls@From dc rd@To
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 (a) Have you ever been arrested? gk¡@ugha Yes/No
¼[k½ D;k vki ij dHkh eqdnek pyk gS (b) Have you ever been prosecuted? gk¡@ugha Yes/No
¼x½ D;k vki dHkh utjcan j[ks x;s (c) Have you ever been kept under detention? gk¡@ugha Yes/No
¼?k½ D;k vki dHkh canh cuk;s x;s (d) Have you ever been bound down? gk¡@ugha Yes/No
¼M+½ D;k vki ij fdlh fof/k
U;k;ky; }kjk tqekZuk fd;k x;k gS
(e) Have you ever been fined by a Court of
Law?
gk¡@ugha Yes/No
¼p½ D;k vki dHkh fdlh vijk/k ds fy;s
U;k;ky; }kjk nks’kh Bgjk, x, gaS
(f) Have you ever been convicted by a Court of
Law for any offence?
gk¡@ugha Yes/No
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
(g) Have you ever been debarred from any
examination or rusticated by any University or
any other educational authority/institution?
gk¡@ugha Yes/No
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
(h) Have you ever been debarred/disqualified
by any Public Service Commission/Staff
Selection Commission for any of their
examination /selection?
gk¡@ugha Yes/No
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 5
¼>½ bl lk{;kadu QkeZ dks Hkjrs le;
D;k fdlh U;k;ky; esa vkids fo#)
eqdnek py jgk gSa
(i) If any case pending against you in any court
of law at the time of filling up this Attestation
Form?
gk¡@ugha Yes/No
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
(j) Is any case pending against you in any
University or any other educational
authority/institution at the time of filling up
this Attestation Form?
gk¡@ugha Yes/No
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
(k) Whether discharged/expelled/withdrawn
from any training institution under the Govt. or
otherwise?
gk¡@ugha Yes/No
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
(l) If the answer to any of the above mentioned
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.
gk¡@ugha Yes/No
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)
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 6
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;kssa 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
Name, designation and full address of the appointing authority.
Director, PGIMER Chandigarh
¼2½ in ftlds fy, mEehnokj ds laca/k eSa fopkj fd;k tk jgk gSA
Post for which the candidate is being considered.
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
Page 1 of 2
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 ___________________________
S.
No.
Name of family
member(s)
Date of
Birth
Relationship
with employee
Income from
Pension/other
sources
Remarks
I hereby undertake to keep the above particulars up-to date by notifying to the Head of
Office any addition/alteration.
Place: ________________
Date: ________________ (Signature)
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
Page 2 of 2
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)
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
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, CHANDIGARH
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, CHANDIGARH
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, CHANDIGARH
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)
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Affix
recent photograph of
3.5 cm × 2.5 cm size /
Passport size
NATIONAL PENSION SYSTEM (NPS) – SUBSCRIBER REGISTRATION FORM
Central Recordkeeping Agency (CRA) - Protean eGov Technologies Limited (formerly NSDL e-Governance Infrastructure Ltd.)
Please select your category
[ Please tick() ]
Central Govt.
Central Autonomous Body
All Citizen Model
NPS Lite (GDS)
State Govt.
State Autonomous Body
Corporate Sector
To,
National Pension System Trust.
Dear Sir/Madam,
I hereby request that an NPS account be opened in my name as per the particulars given below:
* indicates mandatory fields. Please fill the form in English and BLOCK letters with black ink pen. (Refer general guidelines at instructions page)
KYC Number, Retirement Adviser Code and Spouse Name fields are not applicable for Government & NPS Lite Subscribers
KYC Number (if applicable) Generated from Central KYC Registry
Retirement Adviser Code (If applicable)
1. PERSONAL DETAILS: (Please refer to Sr. No.1 of the instructions)
Name of Applicant in full			 Shri 		 Smt. 		 Kumari
First Name*
Middle Name
Last Name
Subscriber’s Maiden Name (if any)
Father's Name* F i r s t M i d d l e L a s t
(Refer Sr. No. 1 of instructions)
Mother’s Name* F i r s t M i d d l e L a s t
(Refer Sr. No. 1 of instructions)
Father’s name will be printed on PRAN card. In case, mother’s name to be printed instead of father’s name [ Please tick () ]
Date of Birth* d d / m m / y y y y (Date of Birth should be supported by relevant documentary proof)
City of Birth*
Country of Birth*
Gender* [ Please tick () ] Male 		 Female 		 Others Nationality*   Indian
Marital Status* Married 		 Unmarried 		 Others
Spouse Name* F i r s t M i d d l e L a s t
(Refer Sr. No. 1 of instructions)
Residential Status* Indian
2. PROOF OF IDENTITY (Pol)* (Any one of the documents need to be provided along with the identification number)
Passport Passport Expiry Date d d / m m / y y y y
Voter ID Card PAN Card
Driving License Driving License Expiry Date d d / m m / y y y y
NREGA JOB Card
Others Name of the ID I D N u m b e r Please refer Sr. No. 2 of the instructions.
UID (Aadhaar) (UIDI [ Aadhaar] number not required.)
As per the amendments made under Prevention of Money-Laundering (Maintenance of Records) Second Amendment Rules, 2019, PAN or Form 60 is mandatory under NPS.If you do not have PAN
at present, please ensure that these details are provided within six months of submission of this Subscriber Registration Form.
3. PROOF OF ADDRESS (PoA)* Correspondence Address Permanent Address
[ Please tick (), as applicable ]
#Not more than 2 months old.
Please refer Sr. No. 2 of the instructions
Passport /Driving License/UID (Aadhaar)/Voter ID card/NREGA Job
Card/Ration Card/Others
Passport /Driving License/UID (Aadhaar)/Voter ID card/NREGA Job
Card/Ration Card/Others
Registered Lease/Sale agreement of residence/Municipal Tax
Receipt
Registered Lease/Sale agreement of residence/Municipal Tax
Receipt
#Latest Piped Gas/Water/Electricity/Telephone[Landline or postpaid
mobile] Bill
#Latest Piped Gas/Water/Electricity/Telephone[Landline or postpaid
mobile] Bill
4.1 CORRESPONDENCE ADDRESS DETAILS*
Address Type* Residential/Business Residential Business Registered Office Unspecified
Flat/Room/Door/Block no. Landmark
Premises/Building/Village
Road/Street/Lane
Area/Locality/Taluk
City/Town/District PIN Code
State/U.T. C o u n t r y
4.2 PERMANENT ADDRESS DETAILS*		 Tick () in the box in case the address is same as above.
Address Type* Residential/Business Residential Business Registered Office Unspecified
Flat/Room/Door/Block no. Landmark
Premises/Building/Village
Road/Street/Lane
Area/Locality/Taluk
City/Town/District PIN Code
State/U.T. C o u n t r y
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5. CONTACT DETAILS
Tel. (Off) (with STD code) + Tel. (Res): (with STD code) +
Mobile* (Mandatory) + 9 1 (Mobile Number is required for communication and to get SMS alerts)
Email ID
6. OTHER DETAILS ( Please refer to Sr no. 3 of the instructions )
 Occupation Details* [ please tick() ]
		 Private Sector Public Sector Government Sector Professional
		 Self Employed Homemaker Student Others (Please Specify)
 Income Range (per annum) Upto 1 lac 1 lac to 5 lac 5 lac to 10 lac 10 lac to 25 lac 25 lac and above
 Educational Qualifications	  Below SSC SSC HSC Graduate Masters Professionals ( CA, CS, CMA, etc.)
 Please Tick If Applicable Politically exposed person Related to Politically exposed Person (Please refer instruction no.3)
7. SUBSCRIBER BANK DETAILS* ( Please refer to Sr no. 4 of the instructions )
(All the bank details are mandatory except MICR Code.)
Account Type [ please tick() ]		 Savings A/c Current A/c
Bank A/c Number
Bank Name
Branch Name
Branch Address PIN Code
State/U.T. C o u n t r y
Bank MICR Code IFS Code
8. SUBSCRIBERS NOMINATION DETAILS* (Nomination details are mandatory. Please refer to Sr. No . 5 of the instructions)
	
Name of the Nominee (You can nominate up to a maximum of 3 nominees and if you desire so please fill in Annexure III (Additional Nomination Form) provided separately)
First Name Middle Name Last Name
Relationship with the Nominee
Date of Birth (In case of Minor) d d / m m / y y y y
Nominee’s Guardian Details (in case of a minor)
First Name Middle Name Last Name
9. NPS OPTION DETAILS (Please tick () as applicable)

I would like to subscribe for Tier II Account also YES NO If Yes, please submit details in Annexure I.
	
(If you wish to activate Tier II account subsequently, you may submit separate application (Annexure S10) to the associated Nodal Office or to POP/POP-SP of your choice. The list of POP/
POP-SPs rendering services under NPS and Annexure S10 is available on CRA website)
I would like my PRAN to be printed in Hindi		 YES NO If Yes, please submit details on Annexure II
10. PENSION FUND (PF) SELECTION AND INVESTMENT OPTION* ( Please refer to Sr no. 6 of the instructions )
(i)	
PENSION FUND SELECTION (Tier I) : Please read below conditions before opting for the choice of Pension Funds:
		1.	
Government Sector: The following Pension Funds (PFs) will act jointly as default PFs, if choice is not exercised by the government employee/subscriber
(a) LIC Pension Fund Limited (b) SBI Pension Funds Pvt. Limited (c) UTI Retirement Solutions Ltd. In case of Central Autonomous Bodies (CAB)/ State Government
(SG)/State Autonomous Bodies (SAB) employees, selection made under this section will be ignored, if choice to employees is not notified by the respective State
Govt/Ministry.
		2.	
All Citizen Model: Subscribers under All Citizen model have the option to choose the available PFs as per their choice in the table below.
		3.	
Corporate Model: Subscribers shall have the option to choose the available PFs as per the below table in consultation with their respective Employer.
		4. NPS Lite: NPS Lite is a group choice model where subscriber has a choice of PF and investment option as available with Aggregator.
Name of the Pension Fund (Please select only one) Please Tick () Default Choice of Pension Funds
LIC Pension Fund Limited
Available in Government sector, if employee/subscriber does not exercise
choice of PF
SBI Pension Funds Private Limited
UTI Retirement Solutions Limited
ICICI Prudential Pension Funds Management Company Limited
Kotak Mahindra Pension Fund Limited
HDFC Pension Management Company Limited
Aditya Birla Sun life Pension Management Limited
			 * 
Selection of 01 Pension Fund is mandatory for All Citizen subscriber
(ii) INVESTMENT OPTION
		 (Please Tick () in the box given below showing your investment option).
		 Active Choice 		 Auto Choice
		 Please note:
		 1. In case you select Active Choice fill up section (iii) below and if you select Auto Choice fill up section (iv) below.
		 2. In case you do not indicate any investment option, your funds will be invested in Auto Choice (LC 50).
		 3. 	
In case you have opted for Auto Choice and fill up section (iii) below relating to Asset Allocation, the Asset Allocation instructions will be ignored and investment will
be made as per Auto Choice (LC 50).
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(iii) ACTIVE CHOICE – ASSET ALLOCATION (to be filled up only in case you have selected ‘Active Choice’ the investment option)
Asset Class
E
(Cannot
exceed 75%)
C
(Max up to
100%)
G
(Max up to
100%)
A
(Cannot
exceed 5%)
Total Asset class E-Equity and related instruments; Asset class C-Corporate debt and related
instruments; Asset class G - Government Bonds and related instruments; Asset Class
A-Alternative Investment Funds including instruments like CMBS, MBS, REITS, AIFs, Invlts etc.
Specify % 100%
Choices in
Govt sector
Not available Available
Not
available
In case of Government employee/subscriber the Active choice of Asset Allocation is restricted to Asset
Class ‘G’ only
		 Please note:
		 1. Upto 50 years of age, the maximum permitted Equity Investment is 75% of the total asset allocation.
		 2.	
From 51 years and above, maximum permitted Equity Investment will be as per the equity allocation matrix provided in Annexure A. The tapering off of equity
allocation will be carried out as per the matrix on date of birth.
		 3.	
The total allocation across E, C, G and A asset classes must be equal to 100%. In case, the allocation is left blank and/or does not equal 100%, the application shall
be rejected.
(iv)	
AUTO CHOICE OPTION (to be filled up only in case you have selected the ‘Auto Choice’ investment option). In case, you do not indicate
a choice of LC, your funds will be invested as per LC 50.
Life Cycle (LC)
Funds
Please Tick ()
Only One
Choices in Govt
sector Note: 1. LC 75- It is the Life cycle fund where the Cap to Equity investments is 75% of the total asset
2. LC 50- It is the Life cycle fund where the Cap to Equity investments is 50% of the total asset
3. LC 25- It is the Life cycle fund where the Cap to Equity investments is 25% of the total asset
4. Govt. employee can exercise Auto Choice of Asset Allocation for LC 25  LC 50 only
LC 75 Not available
LC 50
Available
LC 25
11. DECLARATION ON FATCA* (Foreign Account Tax Compliance Act) COMPLIANCE (Please refer to Sr no. 7 of the instructions):
Section I*
US Person*   Yes    No
Section II*
For the purposes of taxation, I am a resident in the following countries and my Tax Identification Number (TIN)/functional equivalent in each country is set
out below or I have indicated that a TIN/functional equivalent is unavailable (kindly fill details of all countries of tax residence if more than one):
Particulars Country (1) Country (2) Country (3)
Country/countries of tax residency
Address in the jurisdiction for Tax
Residence
Address Line 1
City/Town/Village
State
ZIP/Post Code
Tax Identification Number (TIN)/Functional equivalent Number
TIN/ Functional equivalent Number Issuing Country
Validity of documentary evidence provided (Wherever applicable) dd / mm / yyyy dd / mm / yyyy dd / mm / yyyy
“I certify that:
a) It shall be my responsibility to educate myself and to comply at all times with all relevant laws relating to reporting under section 285BA of the Act read with the
Rules 114F to 114H of the Income tax Rules, 1962 thereunder and the information provided in the Form is in accordance with the aforesaid rules,
b) the information provided by me in the Form, its supporting Annexures as well as in the documentary evidence are, to the best of my knowledge and belief, true,
correct and complete and that I have not withheld any material information that may affect the assessment/categorization of the account as a Reportable account
or otherwise.
c) I permit/authorise the NPS Trust to collect, store, communicate and process information relating to the Account and all transactions therein, by the NPS Trust
and any of NPS intermediaries wherever situated including sharing, transfer and disclosure between them and to the authorities in and/or outside India of any
confidential information for compliance with any law or regulation whether domestic or foreign.
d) I undertake the responsibility to declare and disclose within 30 days from the date of change, any changes that may take place in the information provided in
the Form, its supporting Annexures as well as in the documentary evidence provided by me or if any certification becomes incorrect and to provide fresh self-
certification along with documentary evidence,
e) I also agree that in case of my failure to disclose any material fact known to me, now or in future, the NPS Trust may report to any regulator and/or any authority
designated by the Government of India (GOI) /RBI/IRDA/PFRDA for the purpose or take any other action as may be deemed appropriate by the NPS Trust if the
deficiency is not remedied by me within the stipulated period.
f) I hereby accept and acknowledge that the NPS Trust shall have the right and authority to carry out investigations from the information available in public domain
for confirming the information provided by me to the NPS Trust
g) I also agree to furnish such information and/or documents as the NPS Trust may require from time to time on account of any change in law either in India or
abroad in the subject matter herein.
h) I shall indemnify NPS Trust for any loss that may arise to the NPS Trust on account of providing incorrect or incomplete information.
Date d d / m m / y y y y
Place :
Signature/Thumb Impression* of Subscriber in black ink
(* LTI in case of male and RTI in case of females)
Name of subscriber
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12. DECLARATION BY SUBSCRIBER* ( Please refer to Sr no. 8 of the instructions )
Declaration  Authorization by all subscribers
	
I have read and understood the terms and conditions of the National Pension System and hereby agree to the same along with the PFRDAAct, regulations framed thereunder
and declare that the information and documents furnished by me are true and correct, to the best of my knowledge and belief. I undertake to inform immediately the Central
Record Keeping Agency/National Pension System Trust, of any change in the above information furnished by me. I do not hold any pre-existing account under NPS. I
understand that I shall be fully liable for submission of any false or incorrect information or documents.
	
I further agree to be bound by the terms and conditions of provision of services by CRA, from time to time and any amendment thereof as approved by PFRDA, whether
complete or partial without any new declaration being furnished by me. I shall be bound by the terms and conditions for the usage of I-PIN (to access CRA website and view
details)  T-PIN.
Declaration under the Prevention of Money Laundering Act, 2002
	
I hereby declare that the contribution paid by me/on my behalf has been derived from legally declared and assessed sources of income. I understand that NPS Trust has
the right to peruse my financial profile or share the information, with other government authorities. I further agree that NPS Trust has the right to close my PRAN in case I am
found violating the provisions of any law relating to prevention of money laundering.
Date d d / m m / y y y y
Place :
Signature/Thumb Impression* of Subscriber in black ink
(* LTI in case of male and RTI in case of females)
13. DECLARATION BY EMPLOYER
Applicable to Government Subscribers only
(Subscribers Employment Details to be filled and attested by the Deptt. (All Details are Mandatory)
Date of Joining d d / m m / y y y y Date of Retirement d d / m m / y y y y
Employee Code/ID (If applicable)
PPAN (If applicable)
Employee Code/ID and PPAN are optional. If you intend
to provide, mention any one.
Group of Employee (Tick as applicable)		 Group A 			 Group B 		 Group C 		 Group D
Office
Department
Ministry
DDO Registration Number
DTO/PAO/CDDO/DTA/PrAO Registration Number
Basic Pay
Pay Scale
	
It is certified that the details provided in this subscriber registration form by ___________________________________ employed with us, including
the address and employment details provided above are as per the service record of the employee maintained by us. Also, it is further certified that
he/she has read entries/entries have been read over to him/her by us and got confirmed by him/her.
Signature of the Authorised person
(In the box above)
Rubber Stamp of the DDO
(In the box above)
Signature of the Authorised person
(In the box above)
Rubber Stamp of the DTO/PAO/CDDO/
DTA/PrAO (In the box above)
Designation of the Authorised Person
Name of the DDO
Deptt/Ministry
Designation of the Authorised Person
Name of DTO/PAO/CDDO/DTA/PrAO
Date d d / m m / y y y y
14. DECLARATION BY EMPLOYER/ CORPORATE
Applicable to Corporate Subscribers only
(Subscribers Employment Details to be filled and attested by Corporate (All Details are Mandatory))
Date of Joining d d / m m / y y y y Date of Retirement d d / m m / y y y y
Employee Code/ID
Corporate Regd. Number (CHO No.) Allotted by CRA
CBO No. allotted by CRA
Certified that the details provided in this subscriber registration form by ___________________________________ employed with us, including the
employment details provided above are as per the service record of the employee maintained by us. Also, it is further certified that he / she has read the
entries / entries have been read over to him / her by us and got confirmed by him / her.
Date d d / m m / y y y y Place
Signature of the Authorised person (In the box above)
Designation of the Authorised Person Rubber Stamp of the Corporate (In the box above)
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15. DECLARATION BY THE AGGREGATOR
Applicable to NPS Lite Subscribers
Authorisation by Aggregator’s office (NL - AO)
	
Certified that the subscriber is registered with the aggregator and he/she has opted to join NPS. I hereby declare that the subscriber is eligible to join NPS
and the above declaration has been signed /thumb impressed before me by ...................................................after (s)he has read the entries/ entries have
been read over to her/him by me.
Signature of the Authorised person (In the box above) Rubber Stamp of the Aggregator (In the box above)
Name of the Aggregator
NPS Lite Account Office (NL-AO) Registration Number NPS Lite - Collection Centre (NL - CC) Registration Number
Membership No. allotted by Aggregator (if any)
Place Date d d / m m / y y y y
16. TO BE FILLED BY POP-SP
Receipt No. (17 digits) POP-SP Registration Number
Document accepted for date of Birth Proof:
Copy of PAN card submitted YES NO 					 KYC Compliance YES NO
Documents Received: (Originals Verified) Self Certified (Attested) True Copies
Identity Verification : Done
Existing Customer:
	
I/we hereby certify/confirm that Shri/Smt/Kum ......................... is an existing KYC verified customer The above applicant is having an operative Bank/
Demat/Folio/.......................account (specify nature of the account) having account number/client ID.......................maintained at..............branch/office.
The KYC documents available with us for this customer/client matches the requirement for opening NPS account and are in compliance with PMLA
Rules. I / We further confirm that the Savings Bank a/c of Sh/Smt/Kum ...................... is not a ‘Basic Savings Bank Deposit Account (applicable in case
of Bank PoP)
To be filled by POP-SP
Name:
Designation: Place:
POP-SP Seal Signature of Authorized Signatory Date d d / m m / y y y y
[To be filled by CRA - Facilitation Centre (CRA-FC)]
Received by CRA-FC Registration Number
Received at Date d d / m m / y y y y
Acknowledgement Number (by CRA-FC)
PRAN Allotted
ACKNOWLEDGEMENT
Name of the Subscriber:
Contribution Amount Remitted:			 `
Date of Receipt of Application and Contribution Amount: d d / m m / y y y y
											
Stamp and Signature of the Employer/PoP:
CSRF
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INSTRUCTIONS FOR FILLING THE SUBSCRIBER REGISTRATION FORM
General Guidelines
(a) 	 Please fill the form in legible handwriting so as to avoid errors in your application processing. Please do not overwrite. Corrections should be made by cancelling and re-writing
and such corrections should be countersigned by the applicant. Each box, wherever provided, should contain only one character (alphabet / number / punctuation mark) leaving
a blank box after each word.
(b) In case, you mention the KYC number submission of proof for the same is necessary.
(c) 	 Applications incomplete in any respect and/or not accompanied by required documents are liable to be rejected. The application is liable to be rejected if mandatory fields are
left blank or the application form is printed back to back
(d) 	 The subscriber should not sign across the photograph. The photograph should not be stapled or clipped to the form. If there is any mark on the photograph such that it hinders
the clear visibility of the face of the subscriber, the application shall not be accepted.
(e) Copies of all the documents submitted by the applicant should be self-attested and accompanied by originals for verification by the nodal office.
(f) Name and Address of the applicant mentioned on the form, should match with the documentary proof submitted.
(g) The subscriber’s thumb’s impression should be verified by the designated officer of POP-SP / Nodal Office.
S.
No
Item
No.
Item Details Instructions
1 1
Personal Details
i.	
This Form is applicable only for Resident Indians. There is a separate Form for Non Resident Indians  Overseas Citizen of India.
ii. Currently, Foreign Nationals / Other Country Individuals (OCI) and Persons of Indian Origin (PIO) are not allowed to open PRAN.
iii. The applicant shall mention father’s name and mother’s name and shall select the option to be printed on PRAN Card.
Spouse Name If married, spouse name is mandatory.
Father’s Name
i.	
Father’s name is mandatory.
ii. If Father’s name has more than 30 digits, you may fill Annexure II for the same.
Mother’s Name
i. Mother’s name is mandatory
ii. If Mother’s name has more than 30 digits, you may fill Annexure II for the same.
Date of Birth Please ensure that the date of birth matches as indicated in the document provided in the support.
2 2, 3  4
Identity,
Correspondence 
Permanent address
details
S.No Proof of Identity (Copy of any one) S.No Proof of Address (Copy of any one)
1 Passport issued by Government of India. 1 Passport issued by Government of India
2 Ration card with photograph. 2 Ration card with photograph and residential address
3 Bank Pass book or certificate with Photograph. 3 Bank Pass book or certificate with photograph and residential
address
4 Certificate of the POP for an existing customer. 4 Certificate of the POP for an existing customer.
5 Voters Identity card with photograph and residential address. 5 Voters Identity card with photograph and residential address
6 Valid Driving license with photograph 6 Valid Driving license with photograph and residential address
7 Certificate of identity with photograph signed by a Member of
Parliament or Member of Legislative Assembly
7 Letter from any recognized public authority at the level of
Gazetted officer like District Magistrate, Divisional commissioner,
BDO, Tehsildar, Mandal Revenue Officer, Judicial Magistrate etc.
8 PAN Card issued by Income tax department 8 Certificate of address with photograph signed by a Member of
Parliament or Member of Legislative Assembly
9 Aadhar Card / letter issued by Unique Identification Authority
of India
9 Aadhar Card / letter issued by Unique Identification Authority of
India clearly showing the address
10 Job cards issued by NREGA duly signed by an officer of the
State Government
10 Job cards issued by NREGA duly signed by an officer of the
State Government
11 Identity card issued by Central/State government and its
Departments, Statutory/ Regulatory Authorities, Public Sector
Undertakings, Scheduled commercial Banks, Public Financial
Institutions, Colleges affiliated to universities and Professional
Bodies such as ICAI, ICWAI, ICSI, Bar Council etc.
11 The identity card/document with address or letter of allotment
of accommodation issued by any of the following: Central/
State Government and its Departments, Statutory/Regulatory
Authorities, Public Sector Undertakings, Scheduled Commercial
Banks, Financial Institutions and listed companies for their
employees. Pension or Family Pension Payment Orders issued
by Govt. Departments or PSU containing address.
12 Photo. Identity Card issued by Defence, Paramilitary and
Police department’s
12 Latest Electricity/water/piped gas bill in the name of the Subscriber
/ Claimant and showing the address (less than 2 months old)
13 Ex-Service Man Card issued by Ministry of Defence to their
employees.
13 Latest Telephone bill (landline  postpaid mobile) in the name of
the Subscriber / Claimant and showing the address (less than 2
months old)
14 Photo Credit card. 14 Latest Property/house Tax receipt (not more than one year old)
15 Existing valid registered lease agreement of the house on stamp
paper ( in case of rented/leased accommodation)
Note:
(i)	
If the address on the document submitted for identity proof by the prospective customer is same as that declared by him/her in the account
opening form, the document may be accepted as a valid proof of both identity and address.

(ii) 
If the address indicated on the document submitted for identity proof differs from the current address mentioned in the account opening
form, a separate proof of address should be obtained.All future communications will be sent to correspondence address. If correspondence
 Permanent address are different, then proof for both have to be submitted.
(iii) The KYC documents may be submitted within a period of 30 days after generation of PRAN. (Only for Government Subscribers)
3 6
Politically Exposed
Person
Politically Exposed Persons’ (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, for
example heads of state or of the government, senior politicians, senior government, judicial or military officials, senior executives of state-
owned corporations, important political party officials.
4 7
Subscriber’s Bank
Details
For Tier I  Tier II account, bank details are mandatory and it should be supported by a documentary proof. Please attach a cancelled cheque
containing Subscriber Name, Bank Name, Bank Account Number and IFS Code. If cheque is not available or cheque is not preprinted with
Subscriber name, a copy of bank passbook or bank statement or bank certificate or letter from Bank mentioning Subscriber Name, Bank
Name, Bank Account No. and IFS Code should be submitted.
5 8
Subscriber’s
Nomination Details
Nomination details are mandatory. In case of more than one nominee, percentage share value for all the nominees must be integer. Decimals/
Fractional values shall not be accepted in the nomination(s). 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.
6 10
Pension Fund (PF)
Selection and
Investment Option
Government employee/subscribers can exercise choice of Pension Funds and allocate their investments either in Asset Class‘G’ under’
Actice Choice’ and in Life Cycle Funds - LC 50 or LC 25 under ‘Auto Choice’. In case a Government employee/subscribers does not exercises
the choices of Pension Fund, their contributions will be allocated among 03 Pension Funds namely (i) LIC Pension Fund Limited (ii) SBI
Pension Funds Pvt. Limited (iii) UTI Retirement Solutions Ltd.
7 11
Declaration by
subscriber on FATCA
Compliance
Clarification / Guidelines on filling details if applicant residence for tax purposes in jurisdiction(s) outside India
•	
Jurisdiction(s) of Tax Residence: Since US taxes the global income of its citizen, every US citizen of whatever nationality, is also a resident
for tax purpose in USA.
• 	
Tax identification Number (TIN): TIN need not be reported if it has not been issued by the jurisdiction. However, if the said jurisdiction has
issued a high integrity number with an equivalent level of identification (a “Functional equivalent”), the same may be reported. Examples
of that type of number for individual include, a social security/insurance number, citizen/personal identification/services code/number and
resident registration number)
• 
If applicant residence for tax purpose in jurisdiction(s) within India, Permanent Account Number (PAN) to be provided as Tax Identification Number (TIN)
•	
In case applicant is declaring US person status as ‘No’ but his/her Country of Birth is US, document evidencing Relinquishment of
Citizenship should be provided or reasons for not having relinquishment certificate is to be provided
8 12
Declaration by
Subscriber
Signature / Thumb impression should only be within the box provided in the form. Thumb impression, if used, should be attested by the
designated officer of POP/POP-SP/Nodal office with the official seal and stamp. Left Thumb Impression in case of males and Right Thumb
Impression in case of females.
General Information for Subscribers
a) The Subscriber can obtain the status of his/her application from CRA and their designated nodal officer.
b) Subscribers are advised to retain the acknowledgement slip signed/ stamped by the designated nodal officer where they submit the application.
c) For more information / clarifications, contact CRA:
Website: https://www.npscra.nsdl.co.in
Call: 022-4090 4242
Address: Central Recordkeeping Agency (CRA)
Protean eGov Technologies Limited
(formerly NSDL e-Governance Infrastructure Limited)
1st Floor, Times Tower, Kamala Mills Compound, Senapati Bapat Marg,
Lower Parel (W), Mumbai - 400013
Equity Allocation Matrix for Active Choice
Age (years) Max. Equity Allocation
Upto 50 75%
51 72.50%
52 70%
53 67.50%
54 65%
55 62.50%
56 60%
57 57.50%
58 55%
59 52.50%
60  above 50%
Please note:
1. Upto 50 years of age, the maximum permitted Equity Investment is 75% of the total asset allocation.
2. From 51 years and above, maximum permitted Equity Investment will be as per the equity allocation matrix provided above. The tapering off of equity
allocation will be carried out as per the matrix on date of birth.
Annexure A to CSRF
Ver 1.5
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
Page 1 of 2
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, CHANDIGARH
Page 2 of 2
FORM–2
Details of Family
[See Rules 10 (3)]
Important
1. The original Form submitted by the Government servant is to be retained. All additions/alterations are to
be communicated by the Government servant/retired Government servant/Subscriber along with the
supporting documents and the changes shall be recorded in this Form under the signature of Head of
Office in column (7). No new Form will substitute the original Form. However, the retiring subscriber
should submit the details of family afresh at the time of retirement.
2. The details of spouse, all children and parents (whether eligible for family pension or not) and disabled
siblings (brothers and sisters) may be given.
3. The Head of Office shall indicate the date of receipt of communication regarding addition or alteration in
the family in the ‘Remarks’ column. The fact regarding disability or change or marital status of a family
member should also be included in the ‘Remarks’ column.
4. Wife and husband shall include judicially separated wife and husband.
5. The retired Government Servant shall attach the details of change in family structure after retirement in
the proforma prescribed under Dept. of PPW, OM No.1(23)-PP.W/91-E dated 04/11/1992.
6. Copies of birth certificates to be attached. Copies of any other relevant certificates, if available, should be
attached.
Name of the
Govt. servant
Designation Nationality
Details of family members:
S.
No.
Name
Date of birth
(DD/MM/YYYY)
Aadhaar
no.*
(voluntary)
Relationship
with Govt.
servant/retired
Govt. servant
Marital
status
Remarks
Dated
signature of
Head of
Office
1 2 3 4 5 6 7
1.
2.
3.
4.
5.
6.
7.
I hereby undertake to keep the above particulars up to date by notifying to the Head of Office any addition or
alteration.
Email: (Optional) Place:
Mobile: Date: (Signature)
* Providing Aadhaar No. is voluntary. However, if it is provided, consent to link it to Bank Account and also for authentication of identity from
UIDAI for pension related purpose only, is presumed.
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
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 and addresses
of nominee/nominees
Relationship
with the Govt.
Servant
Age
* Share of
amount
to be paid
to each
Contingencies on the
happening of which
the nomination shall
become invalid
Name, address, relationship
of persons, if any, to whom
the right of the nominee
shall pass in the event of the
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, CHANDIGARH
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, CHANDIGARH
Page | 1
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: _______________________
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
Page | 2
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.
Sl.
No.
Description
Name and address
of Company, Bank
etc.
Amount
If not in own name, name and
address of person in whose
name held and his/her
relationship with the PGIMER
employee
Annual
Income
derived
Remarks
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)
Sl.
No.
Description
of items
Price or value at the time of
acquisition and/or the total payments
made up to the date of return, as the
case may be in case of articles
purchased on hire purchase or
installment basis
If not in own name, name
and address of the person
in whose name and his/her
relationship with the
PGIMER employee
How acquired
with
approximate
date of
acquisition
Remarks
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.
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
Page | 3
FORM No. IV
Statement of Provident Fund and Life Insurance Policy on First Appointment (recruited in 20___ calendar year)
Insurance Policies
Sl.
No.
Policy No. and
date of Policy
Name of Insurance
Company
Sum insured / date of maturity
Amount of
annual premium
1 2 3 4 5
Provident Fund
Type of Provident
Funds/GPF/CPF/
NPS Account No.
Closing balance as last
reported by the
Audit/Accounts officer
along with date of such
balance
Contribution
made
subsequently
Total
Remarks (if there is dispute
regarding closing balance, the
figures according to the PGIMER
employee should also be
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)
Sl.
No.
Amount
Name and address of
Creditor
Date of
incurring
Liability
Details of
Transaction
Remarks
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).
THROUGHPROPERCHANNEL
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 26.09.1998 and
PG/MA/2000/19831-914, dated 20.04.2000, on the subject noted above, I am to certify as under:
That I am working as . in the Deptt. of PGIMER,
Chandigarhsince  getting Basic Payof 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
_date (Certificate from Transport Office enclosed).
to
That I have not remain absent from duty for the period exceeding 30 days due to tour etc. during the
to
period August 1997 to April 2000 except for the period from_
In view of the above, I may kindly be granted Transport Allowance sanctioned by the Government of
India, Ministry of Finance, Department of vide O.M. No. 21(1) 97/EW(B), dated 3 October-1997.
Thanking you.
Yours faithfully,
Name:
Designation: -_
Emp. Code No_
Deptt.
Forwarded to the Financial Adviser, PGIMER, Chandigarh for necessary action.
HEAD OF THE DEPTT.
Certified by TransportDepartment
has availed/not
Certified that Mr./Ms_
to
availed/Not availing PGI staff Bus facility since
Sr. Technical Officer (Vehicles),
Transport Deptt.
PGIMER, Chandigarh.
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
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
Is Differently abled
Percentage of
Differently abled
Type of Differently
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
State Thana
Nearest Railway
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
Name
Year of Birth Birth Place
Sex Relation Marital Status
Is Dependent Dependent Upto
Dependent
Occupation Details
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration
Family Member
Name
Year of Birth Birth Place
Sex Relation Marital Status
Is Dependent Dependent Upto
Dependent
Occupation Details
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration
Family Member
Name
Year of Birth Birth Place
Sex Relation Marital Status
Is Dependent Dependent Upto
Dependent
Occupation Details
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration
Family Member
Name
Year of Birth Birth Place
Sex Relation Marital Status
Is Dependent Dependent Upto
Dependent
Occupation Details
Dependent Present Address
GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration
Gratuity Gratuity Percentage Gratuity Declaration
Family Member
Name
Year of Birth Birth Place
Sex Relation Marital Status
Is Dependent Dependent Upto
Dependent
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
To Date
Source of
Recruitment
Service Group
Cadre Appointment Date Joining Date
Retirement Date Designation Department
Pay Scale Category Pay Scale Type
Pay Band Pay Scale Grade Pay
Pay Scale Effective
Date
Basic Pay Basic Effective Date
Consolidated Salary
Consolidated Salary
Effective Date
Seniority No.
Seniority Date Next increment Date Current Status
QUALIFICATION DETAILS
Serial No.
Examination
Degree
University/Board Subject Year of Passing Percentage%
LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION  RESEARCH, CHANDIGARH
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, CHANDIGARH
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___________________________
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)
members
Date of
Birth/Age
Sex Relationship Occupation/Income/
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.
Affix passport size
group photo
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)

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sourabh vyas1222222222222222222244444444

  • 1. 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.
  • 2. 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 ________________________________________ 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. The following documents checked and verified from the originals: 1.________________________________ 2. ______________________________ 3.________________________________ 4. ______________________________ 5.________________________________ 6. ______________________________ 7.________________________________ 8. ______________________________ 9.________________________________ 10. _____________________________ 11._______________________________ 12. _____________________________ Dealing Asstt. OS/AAO/AO
  • 3. 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:____________________
  • 4. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 1 mEehnokj }kjk viuh fy[kkoV esa gh Hkjk tkuk pkfg;sA To be filled in by the candidate in his own handwriting. lk{;kadu QkeZ@ATTESTATION FORM psrkouh@WARNING 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 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). miuke@Surname uke@Name 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 gky gh ds ikliksVZ vkdkj ¼3-5 ls-eh- x 4-5 ls-eh-½ ds gLRkk{kfjr QksVks dh izfr fpidkb, Affix singed Passport size (3.5 cm x 4.5 cm approx.) copy of recent photograph
  • 5. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 2 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 ftyk ;k edku u-] xyh@lM+d@ekxZ vkSj uxj½ Residential address in full (i.e.), Village, Thana & Distt. or House No/ Lane/Street/ Road & Town fiNys [kkus esa fn;s x;s LFkku ds ftys ds eq[;ky; dk uke Name of the Dist. H.O. of the place mentioned in the preceding column dc ls@From dc rd@To 5- ¼d½ (a) fj'rk uke Relation Name jk"Vªh;rk ¼tUe ls vkSj@;k vf/kokl ls½ Nationality (by birth and/or by domicile) tUe dk LFkku Place of birth O;olk; ¼;fn lsok esa gks rks iwjk inuke vkSj dk;kZy; dk iwjk irk fn;k tk;s½ Occupation (if employed give full designation & Official address) orZeku Mkd dk irk ¼;fn e`rd gks rks fiNyk irk½ Present Postal address (if dead give last address) ?kj dk LFkkbZ irk Permanent Home 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)
  • 6. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 3 ¼[k½ fons’k esa i<+ jgs@jg jgs iq= ¼iq=ksa½ vkSj@;k iq=h ¼iqf=;ksaa½ 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. uke Name jk"Vªh;rk ¼tUe ls vkSj@;k vf/kokl ls½ Nationality (by birth and/or by domicile) tUe dk LFkku Place of birth ns'k dk uke tgka i<+ jgs@jg jgs gSa iwjk irk Country in which studying/ living with full address fiNys dkye esa fn;s x;s ns'k esa ftl rkjh[k ls jgs gS Date from which studying/living in the country 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;@vuqlwfpr tkfr@ vuqlwfpr tutkfr@ vU; fiNM+k oxZ½@Category (UR/SC/ST/OBC) (iv) (v) fodykaxrk ¼vks-,p-@,p-,p-@oh-,p-½@ Person with Disability (OH/HH/VH) (v) (vi) /keZ@Religion (vi) 8. O;fDrxr igpku dh fu'kkuh Personal Marks of identification (i) (ii) 9. (i) tUe LFkku] ftyk vkSj jkT; ftlesa ;g fLFkr gS Place of birth, Distt & State in which situated (i) (ii) vki fdl ftys vkSj jkT; ds gS Distt. & State to which you belong (ii) (iii) vkids firk ewy #i ls fdl ftys vkSj jkT; ds gS Distt. & State to which your father belongs (iii) 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 Educational qualifications showing places of education with years in Schools and College since the 15 th Year age. Ldwy@dkyst dk uke vkSj iwjk irk Name of School/College with full address izos'k dh rkjh[k Date of entering NksM+us dh rkjh[k Date of Leaving ijh{kk mrhZ.k dh Examination Passed
  • 7. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 4 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 Lo#i Designation, emoluments and nature of employment fu;ksDrk dk iwjk uke o iRkk Full name and address of employer igyh ukSdjh NksM+us dk dkj.k Reasons of leaving previous service dc ls@From dc rd@To 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 (a) Have you ever been arrested? gk¡@ugha Yes/No ¼[k½ D;k vki ij dHkh eqdnek pyk gS (b) Have you ever been prosecuted? gk¡@ugha Yes/No ¼x½ D;k vki dHkh utjcan j[ks x;s (c) Have you ever been kept under detention? gk¡@ugha Yes/No ¼?k½ D;k vki dHkh canh cuk;s x;s (d) Have you ever been bound down? gk¡@ugha Yes/No ¼M+½ D;k vki ij fdlh fof/k U;k;ky; }kjk tqekZuk fd;k x;k gS (e) Have you ever been fined by a Court of Law? gk¡@ugha Yes/No ¼p½ D;k vki dHkh fdlh vijk/k ds fy;s U;k;ky; }kjk nks’kh Bgjk, x, gaS (f) Have you ever been convicted by a Court of Law for any offence? gk¡@ugha Yes/No 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 (g) Have you ever been debarred from any examination or rusticated by any University or any other educational authority/institution? gk¡@ugha Yes/No 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 (h) Have you ever been debarred/disqualified by any Public Service Commission/Staff Selection Commission for any of their examination /selection? gk¡@ugha Yes/No
  • 8. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 5 ¼>½ bl lk{;kadu QkeZ dks Hkjrs le; D;k fdlh U;k;ky; esa vkids fo#) eqdnek py jgk gSa (i) If any case pending against you in any court of law at the time of filling up this Attestation Form? gk¡@ugha Yes/No 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 (j) Is any case pending against you in any University or any other educational authority/institution at the time of filling up this Attestation Form? gk¡@ugha Yes/No 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 (k) Whether discharged/expelled/withdrawn from any training institution under the Govt. or otherwise? gk¡@ugha Yes/No 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 (l) If the answer to any of the above mentioned 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. gk¡@ugha Yes/No 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)
  • 9. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH The Director, PGIMER Chandigarh, Sector-12, Chandigarh-160012 Page | 6 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;kssa 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 Name, designation and full address of the appointing authority. Director, PGIMER Chandigarh ¼2½ in ftlds fy, mEehnokj ds laca/k eSa fopkj fd;k tk jgk gSA Post for which the candidate is being considered.
  • 10. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH Page 1 of 2 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 ___________________________ S. No. Name of family member(s) Date of Birth Relationship with employee Income from Pension/other sources Remarks I hereby undertake to keep the above particulars up-to date by notifying to the Head of Office any addition/alteration. Place: ________________ Date: ________________ (Signature)
  • 11. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH Page 2 of 2 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)
  • 12. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 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)
  • 13. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 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.
  • 14. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 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
  • 15. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx<+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 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)
  • 16. CSRF Ver 1.5 1 of 5 Affix recent photograph of 3.5 cm × 2.5 cm size / Passport size NATIONAL PENSION SYSTEM (NPS) – SUBSCRIBER REGISTRATION FORM Central Recordkeeping Agency (CRA) - Protean eGov Technologies Limited (formerly NSDL e-Governance Infrastructure Ltd.) Please select your category [ Please tick() ] Central Govt. Central Autonomous Body All Citizen Model NPS Lite (GDS) State Govt. State Autonomous Body Corporate Sector To, National Pension System Trust. Dear Sir/Madam, I hereby request that an NPS account be opened in my name as per the particulars given below: * indicates mandatory fields. Please fill the form in English and BLOCK letters with black ink pen. (Refer general guidelines at instructions page) KYC Number, Retirement Adviser Code and Spouse Name fields are not applicable for Government & NPS Lite Subscribers KYC Number (if applicable) Generated from Central KYC Registry Retirement Adviser Code (If applicable) 1. PERSONAL DETAILS: (Please refer to Sr. No.1 of the instructions) Name of Applicant in full Shri Smt. Kumari First Name* Middle Name Last Name Subscriber’s Maiden Name (if any) Father's Name* F i r s t M i d d l e L a s t (Refer Sr. No. 1 of instructions) Mother’s Name* F i r s t M i d d l e L a s t (Refer Sr. No. 1 of instructions) Father’s name will be printed on PRAN card. In case, mother’s name to be printed instead of father’s name [ Please tick () ] Date of Birth* d d / m m / y y y y (Date of Birth should be supported by relevant documentary proof) City of Birth* Country of Birth* Gender* [ Please tick () ] Male Female Others Nationality*   Indian Marital Status* Married Unmarried Others Spouse Name* F i r s t M i d d l e L a s t (Refer Sr. No. 1 of instructions) Residential Status* Indian 2. PROOF OF IDENTITY (Pol)* (Any one of the documents need to be provided along with the identification number) Passport Passport Expiry Date d d / m m / y y y y Voter ID Card PAN Card Driving License Driving License Expiry Date d d / m m / y y y y NREGA JOB Card Others Name of the ID I D N u m b e r Please refer Sr. No. 2 of the instructions. UID (Aadhaar) (UIDI [ Aadhaar] number not required.) As per the amendments made under Prevention of Money-Laundering (Maintenance of Records) Second Amendment Rules, 2019, PAN or Form 60 is mandatory under NPS.If you do not have PAN at present, please ensure that these details are provided within six months of submission of this Subscriber Registration Form. 3. PROOF OF ADDRESS (PoA)* Correspondence Address Permanent Address [ Please tick (), as applicable ] #Not more than 2 months old. Please refer Sr. No. 2 of the instructions Passport /Driving License/UID (Aadhaar)/Voter ID card/NREGA Job Card/Ration Card/Others Passport /Driving License/UID (Aadhaar)/Voter ID card/NREGA Job Card/Ration Card/Others Registered Lease/Sale agreement of residence/Municipal Tax Receipt Registered Lease/Sale agreement of residence/Municipal Tax Receipt #Latest Piped Gas/Water/Electricity/Telephone[Landline or postpaid mobile] Bill #Latest Piped Gas/Water/Electricity/Telephone[Landline or postpaid mobile] Bill 4.1 CORRESPONDENCE ADDRESS DETAILS* Address Type* Residential/Business Residential Business Registered Office Unspecified Flat/Room/Door/Block no. Landmark Premises/Building/Village Road/Street/Lane Area/Locality/Taluk City/Town/District PIN Code State/U.T. C o u n t r y 4.2 PERMANENT ADDRESS DETAILS* Tick () in the box in case the address is same as above. Address Type* Residential/Business Residential Business Registered Office Unspecified Flat/Room/Door/Block no. Landmark Premises/Building/Village Road/Street/Lane Area/Locality/Taluk City/Town/District PIN Code State/U.T. C o u n t r y
  • 17. CSRF Ver 1.5 2 of 5 5. CONTACT DETAILS Tel. (Off) (with STD code) + Tel. (Res): (with STD code) + Mobile* (Mandatory) + 9 1 (Mobile Number is required for communication and to get SMS alerts) Email ID 6. OTHER DETAILS ( Please refer to Sr no. 3 of the instructions )  Occupation Details* [ please tick() ] Private Sector Public Sector Government Sector Professional Self Employed Homemaker Student Others (Please Specify)  Income Range (per annum) Upto 1 lac 1 lac to 5 lac 5 lac to 10 lac 10 lac to 25 lac 25 lac and above  Educational Qualifications   Below SSC SSC HSC Graduate Masters Professionals ( CA, CS, CMA, etc.)  Please Tick If Applicable Politically exposed person Related to Politically exposed Person (Please refer instruction no.3) 7. SUBSCRIBER BANK DETAILS* ( Please refer to Sr no. 4 of the instructions ) (All the bank details are mandatory except MICR Code.) Account Type [ please tick() ] Savings A/c Current A/c Bank A/c Number Bank Name Branch Name Branch Address PIN Code State/U.T. C o u n t r y Bank MICR Code IFS Code 8. SUBSCRIBERS NOMINATION DETAILS* (Nomination details are mandatory. Please refer to Sr. No . 5 of the instructions) Name of the Nominee (You can nominate up to a maximum of 3 nominees and if you desire so please fill in Annexure III (Additional Nomination Form) provided separately) First Name Middle Name Last Name Relationship with the Nominee Date of Birth (In case of Minor) d d / m m / y y y y Nominee’s Guardian Details (in case of a minor) First Name Middle Name Last Name 9. NPS OPTION DETAILS (Please tick () as applicable) I would like to subscribe for Tier II Account also YES NO If Yes, please submit details in Annexure I. (If you wish to activate Tier II account subsequently, you may submit separate application (Annexure S10) to the associated Nodal Office or to POP/POP-SP of your choice. The list of POP/ POP-SPs rendering services under NPS and Annexure S10 is available on CRA website) I would like my PRAN to be printed in Hindi YES NO If Yes, please submit details on Annexure II 10. PENSION FUND (PF) SELECTION AND INVESTMENT OPTION* ( Please refer to Sr no. 6 of the instructions ) (i) PENSION FUND SELECTION (Tier I) : Please read below conditions before opting for the choice of Pension Funds: 1. Government Sector: The following Pension Funds (PFs) will act jointly as default PFs, if choice is not exercised by the government employee/subscriber (a) LIC Pension Fund Limited (b) SBI Pension Funds Pvt. Limited (c) UTI Retirement Solutions Ltd. In case of Central Autonomous Bodies (CAB)/ State Government (SG)/State Autonomous Bodies (SAB) employees, selection made under this section will be ignored, if choice to employees is not notified by the respective State Govt/Ministry. 2. All Citizen Model: Subscribers under All Citizen model have the option to choose the available PFs as per their choice in the table below. 3. Corporate Model: Subscribers shall have the option to choose the available PFs as per the below table in consultation with their respective Employer. 4. NPS Lite: NPS Lite is a group choice model where subscriber has a choice of PF and investment option as available with Aggregator. Name of the Pension Fund (Please select only one) Please Tick () Default Choice of Pension Funds LIC Pension Fund Limited Available in Government sector, if employee/subscriber does not exercise choice of PF SBI Pension Funds Private Limited UTI Retirement Solutions Limited ICICI Prudential Pension Funds Management Company Limited Kotak Mahindra Pension Fund Limited HDFC Pension Management Company Limited Aditya Birla Sun life Pension Management Limited * Selection of 01 Pension Fund is mandatory for All Citizen subscriber (ii) INVESTMENT OPTION (Please Tick () in the box given below showing your investment option). Active Choice Auto Choice Please note: 1. In case you select Active Choice fill up section (iii) below and if you select Auto Choice fill up section (iv) below. 2. In case you do not indicate any investment option, your funds will be invested in Auto Choice (LC 50). 3. In case you have opted for Auto Choice and fill up section (iii) below relating to Asset Allocation, the Asset Allocation instructions will be ignored and investment will be made as per Auto Choice (LC 50).
  • 18. CSRF Ver 1.5 3 of 5 (iii) ACTIVE CHOICE – ASSET ALLOCATION (to be filled up only in case you have selected ‘Active Choice’ the investment option) Asset Class E (Cannot exceed 75%) C (Max up to 100%) G (Max up to 100%) A (Cannot exceed 5%) Total Asset class E-Equity and related instruments; Asset class C-Corporate debt and related instruments; Asset class G - Government Bonds and related instruments; Asset Class A-Alternative Investment Funds including instruments like CMBS, MBS, REITS, AIFs, Invlts etc. Specify % 100% Choices in Govt sector Not available Available Not available In case of Government employee/subscriber the Active choice of Asset Allocation is restricted to Asset Class ‘G’ only Please note: 1. Upto 50 years of age, the maximum permitted Equity Investment is 75% of the total asset allocation. 2. From 51 years and above, maximum permitted Equity Investment will be as per the equity allocation matrix provided in Annexure A. The tapering off of equity allocation will be carried out as per the matrix on date of birth. 3. The total allocation across E, C, G and A asset classes must be equal to 100%. In case, the allocation is left blank and/or does not equal 100%, the application shall be rejected. (iv) AUTO CHOICE OPTION (to be filled up only in case you have selected the ‘Auto Choice’ investment option). In case, you do not indicate a choice of LC, your funds will be invested as per LC 50. Life Cycle (LC) Funds Please Tick () Only One Choices in Govt sector Note: 1. LC 75- It is the Life cycle fund where the Cap to Equity investments is 75% of the total asset 2. LC 50- It is the Life cycle fund where the Cap to Equity investments is 50% of the total asset 3. LC 25- It is the Life cycle fund where the Cap to Equity investments is 25% of the total asset 4. Govt. employee can exercise Auto Choice of Asset Allocation for LC 25 LC 50 only LC 75 Not available LC 50 Available LC 25 11. DECLARATION ON FATCA* (Foreign Account Tax Compliance Act) COMPLIANCE (Please refer to Sr no. 7 of the instructions): Section I* US Person*   Yes    No Section II* For the purposes of taxation, I am a resident in the following countries and my Tax Identification Number (TIN)/functional equivalent in each country is set out below or I have indicated that a TIN/functional equivalent is unavailable (kindly fill details of all countries of tax residence if more than one): Particulars Country (1) Country (2) Country (3) Country/countries of tax residency Address in the jurisdiction for Tax Residence Address Line 1 City/Town/Village State ZIP/Post Code Tax Identification Number (TIN)/Functional equivalent Number TIN/ Functional equivalent Number Issuing Country Validity of documentary evidence provided (Wherever applicable) dd / mm / yyyy dd / mm / yyyy dd / mm / yyyy “I certify that: a) It shall be my responsibility to educate myself and to comply at all times with all relevant laws relating to reporting under section 285BA of the Act read with the Rules 114F to 114H of the Income tax Rules, 1962 thereunder and the information provided in the Form is in accordance with the aforesaid rules, b) the information provided by me in the Form, its supporting Annexures as well as in the documentary evidence are, to the best of my knowledge and belief, true, correct and complete and that I have not withheld any material information that may affect the assessment/categorization of the account as a Reportable account or otherwise. c) I permit/authorise the NPS Trust to collect, store, communicate and process information relating to the Account and all transactions therein, by the NPS Trust and any of NPS intermediaries wherever situated including sharing, transfer and disclosure between them and to the authorities in and/or outside India of any confidential information for compliance with any law or regulation whether domestic or foreign. d) I undertake the responsibility to declare and disclose within 30 days from the date of change, any changes that may take place in the information provided in the Form, its supporting Annexures as well as in the documentary evidence provided by me or if any certification becomes incorrect and to provide fresh self- certification along with documentary evidence, e) I also agree that in case of my failure to disclose any material fact known to me, now or in future, the NPS Trust may report to any regulator and/or any authority designated by the Government of India (GOI) /RBI/IRDA/PFRDA for the purpose or take any other action as may be deemed appropriate by the NPS Trust if the deficiency is not remedied by me within the stipulated period. f) I hereby accept and acknowledge that the NPS Trust shall have the right and authority to carry out investigations from the information available in public domain for confirming the information provided by me to the NPS Trust g) I also agree to furnish such information and/or documents as the NPS Trust may require from time to time on account of any change in law either in India or abroad in the subject matter herein. h) I shall indemnify NPS Trust for any loss that may arise to the NPS Trust on account of providing incorrect or incomplete information. Date d d / m m / y y y y Place : Signature/Thumb Impression* of Subscriber in black ink (* LTI in case of male and RTI in case of females) Name of subscriber
  • 19. CSRF Ver 1.5 4 of 5 12. DECLARATION BY SUBSCRIBER* ( Please refer to Sr no. 8 of the instructions ) Declaration Authorization by all subscribers I have read and understood the terms and conditions of the National Pension System and hereby agree to the same along with the PFRDAAct, regulations framed thereunder and declare that the information and documents furnished by me are true and correct, to the best of my knowledge and belief. I undertake to inform immediately the Central Record Keeping Agency/National Pension System Trust, of any change in the above information furnished by me. I do not hold any pre-existing account under NPS. I understand that I shall be fully liable for submission of any false or incorrect information or documents. I further agree to be bound by the terms and conditions of provision of services by CRA, from time to time and any amendment thereof as approved by PFRDA, whether complete or partial without any new declaration being furnished by me. I shall be bound by the terms and conditions for the usage of I-PIN (to access CRA website and view details) T-PIN. Declaration under the Prevention of Money Laundering Act, 2002 I hereby declare that the contribution paid by me/on my behalf has been derived from legally declared and assessed sources of income. I understand that NPS Trust has the right to peruse my financial profile or share the information, with other government authorities. I further agree that NPS Trust has the right to close my PRAN in case I am found violating the provisions of any law relating to prevention of money laundering. Date d d / m m / y y y y Place : Signature/Thumb Impression* of Subscriber in black ink (* LTI in case of male and RTI in case of females) 13. DECLARATION BY EMPLOYER Applicable to Government Subscribers only (Subscribers Employment Details to be filled and attested by the Deptt. (All Details are Mandatory) Date of Joining d d / m m / y y y y Date of Retirement d d / m m / y y y y Employee Code/ID (If applicable) PPAN (If applicable) Employee Code/ID and PPAN are optional. If you intend to provide, mention any one. Group of Employee (Tick as applicable) Group A Group B Group C Group D Office Department Ministry DDO Registration Number DTO/PAO/CDDO/DTA/PrAO Registration Number Basic Pay Pay Scale It is certified that the details provided in this subscriber registration form by ___________________________________ employed with us, including the address and employment details provided above are as per the service record of the employee maintained by us. Also, it is further certified that he/she has read entries/entries have been read over to him/her by us and got confirmed by him/her. Signature of the Authorised person (In the box above) Rubber Stamp of the DDO (In the box above) Signature of the Authorised person (In the box above) Rubber Stamp of the DTO/PAO/CDDO/ DTA/PrAO (In the box above) Designation of the Authorised Person Name of the DDO Deptt/Ministry Designation of the Authorised Person Name of DTO/PAO/CDDO/DTA/PrAO Date d d / m m / y y y y 14. DECLARATION BY EMPLOYER/ CORPORATE Applicable to Corporate Subscribers only (Subscribers Employment Details to be filled and attested by Corporate (All Details are Mandatory)) Date of Joining d d / m m / y y y y Date of Retirement d d / m m / y y y y Employee Code/ID Corporate Regd. Number (CHO No.) Allotted by CRA CBO No. allotted by CRA Certified that the details provided in this subscriber registration form by ___________________________________ employed with us, including the employment details provided above are as per the service record of the employee maintained by us. Also, it is further certified that he / she has read the entries / entries have been read over to him / her by us and got confirmed by him / her. Date d d / m m / y y y y Place Signature of the Authorised person (In the box above) Designation of the Authorised Person Rubber Stamp of the Corporate (In the box above)
  • 20. CSRF Ver 1.5 5 of 5 15. DECLARATION BY THE AGGREGATOR Applicable to NPS Lite Subscribers Authorisation by Aggregator’s office (NL - AO) Certified that the subscriber is registered with the aggregator and he/she has opted to join NPS. I hereby declare that the subscriber is eligible to join NPS and the above declaration has been signed /thumb impressed before me by ...................................................after (s)he has read the entries/ entries have been read over to her/him by me. Signature of the Authorised person (In the box above) Rubber Stamp of the Aggregator (In the box above) Name of the Aggregator NPS Lite Account Office (NL-AO) Registration Number NPS Lite - Collection Centre (NL - CC) Registration Number Membership No. allotted by Aggregator (if any) Place Date d d / m m / y y y y 16. TO BE FILLED BY POP-SP Receipt No. (17 digits) POP-SP Registration Number Document accepted for date of Birth Proof: Copy of PAN card submitted YES NO KYC Compliance YES NO Documents Received: (Originals Verified) Self Certified (Attested) True Copies Identity Verification : Done Existing Customer: I/we hereby certify/confirm that Shri/Smt/Kum ......................... is an existing KYC verified customer The above applicant is having an operative Bank/ Demat/Folio/.......................account (specify nature of the account) having account number/client ID.......................maintained at..............branch/office. The KYC documents available with us for this customer/client matches the requirement for opening NPS account and are in compliance with PMLA Rules. I / We further confirm that the Savings Bank a/c of Sh/Smt/Kum ...................... is not a ‘Basic Savings Bank Deposit Account (applicable in case of Bank PoP) To be filled by POP-SP Name: Designation: Place: POP-SP Seal Signature of Authorized Signatory Date d d / m m / y y y y [To be filled by CRA - Facilitation Centre (CRA-FC)] Received by CRA-FC Registration Number Received at Date d d / m m / y y y y Acknowledgement Number (by CRA-FC) PRAN Allotted ACKNOWLEDGEMENT Name of the Subscriber: Contribution Amount Remitted: ` Date of Receipt of Application and Contribution Amount: d d / m m / y y y y Stamp and Signature of the Employer/PoP:
  • 21. CSRF Ver 1.5 6 of 5 INSTRUCTIONS FOR FILLING THE SUBSCRIBER REGISTRATION FORM General Guidelines (a) Please fill the form in legible handwriting so as to avoid errors in your application processing. Please do not overwrite. Corrections should be made by cancelling and re-writing and such corrections should be countersigned by the applicant. Each box, wherever provided, should contain only one character (alphabet / number / punctuation mark) leaving a blank box after each word. (b) In case, you mention the KYC number submission of proof for the same is necessary. (c) Applications incomplete in any respect and/or not accompanied by required documents are liable to be rejected. The application is liable to be rejected if mandatory fields are left blank or the application form is printed back to back (d) The subscriber should not sign across the photograph. The photograph should not be stapled or clipped to the form. If there is any mark on the photograph such that it hinders the clear visibility of the face of the subscriber, the application shall not be accepted. (e) Copies of all the documents submitted by the applicant should be self-attested and accompanied by originals for verification by the nodal office. (f) Name and Address of the applicant mentioned on the form, should match with the documentary proof submitted. (g) The subscriber’s thumb’s impression should be verified by the designated officer of POP-SP / Nodal Office. S. No Item No. Item Details Instructions 1 1 Personal Details i. This Form is applicable only for Resident Indians. There is a separate Form for Non Resident Indians Overseas Citizen of India. ii. Currently, Foreign Nationals / Other Country Individuals (OCI) and Persons of Indian Origin (PIO) are not allowed to open PRAN. iii. The applicant shall mention father’s name and mother’s name and shall select the option to be printed on PRAN Card. Spouse Name If married, spouse name is mandatory. Father’s Name i. Father’s name is mandatory. ii. If Father’s name has more than 30 digits, you may fill Annexure II for the same. Mother’s Name i. Mother’s name is mandatory ii. If Mother’s name has more than 30 digits, you may fill Annexure II for the same. Date of Birth Please ensure that the date of birth matches as indicated in the document provided in the support. 2 2, 3 4 Identity, Correspondence Permanent address details S.No Proof of Identity (Copy of any one) S.No Proof of Address (Copy of any one) 1 Passport issued by Government of India. 1 Passport issued by Government of India 2 Ration card with photograph. 2 Ration card with photograph and residential address 3 Bank Pass book or certificate with Photograph. 3 Bank Pass book or certificate with photograph and residential address 4 Certificate of the POP for an existing customer. 4 Certificate of the POP for an existing customer. 5 Voters Identity card with photograph and residential address. 5 Voters Identity card with photograph and residential address 6 Valid Driving license with photograph 6 Valid Driving license with photograph and residential address 7 Certificate of identity with photograph signed by a Member of Parliament or Member of Legislative Assembly 7 Letter from any recognized public authority at the level of Gazetted officer like District Magistrate, Divisional commissioner, BDO, Tehsildar, Mandal Revenue Officer, Judicial Magistrate etc. 8 PAN Card issued by Income tax department 8 Certificate of address with photograph signed by a Member of Parliament or Member of Legislative Assembly 9 Aadhar Card / letter issued by Unique Identification Authority of India 9 Aadhar Card / letter issued by Unique Identification Authority of India clearly showing the address 10 Job cards issued by NREGA duly signed by an officer of the State Government 10 Job cards issued by NREGA duly signed by an officer of the State Government 11 Identity card issued by Central/State government and its Departments, Statutory/ Regulatory Authorities, Public Sector Undertakings, Scheduled commercial Banks, Public Financial Institutions, Colleges affiliated to universities and Professional Bodies such as ICAI, ICWAI, ICSI, Bar Council etc. 11 The identity card/document with address or letter of allotment of accommodation issued by any of the following: Central/ State Government and its Departments, Statutory/Regulatory Authorities, Public Sector Undertakings, Scheduled Commercial Banks, Financial Institutions and listed companies for their employees. Pension or Family Pension Payment Orders issued by Govt. Departments or PSU containing address. 12 Photo. Identity Card issued by Defence, Paramilitary and Police department’s 12 Latest Electricity/water/piped gas bill in the name of the Subscriber / Claimant and showing the address (less than 2 months old) 13 Ex-Service Man Card issued by Ministry of Defence to their employees. 13 Latest Telephone bill (landline postpaid mobile) in the name of the Subscriber / Claimant and showing the address (less than 2 months old) 14 Photo Credit card. 14 Latest Property/house Tax receipt (not more than one year old) 15 Existing valid registered lease agreement of the house on stamp paper ( in case of rented/leased accommodation) Note: (i) If the address on the document submitted for identity proof by the prospective customer is same as that declared by him/her in the account opening form, the document may be accepted as a valid proof of both identity and address. (ii) If the address indicated on the document submitted for identity proof differs from the current address mentioned in the account opening form, a separate proof of address should be obtained.All future communications will be sent to correspondence address. If correspondence Permanent address are different, then proof for both have to be submitted. (iii) The KYC documents may be submitted within a period of 30 days after generation of PRAN. (Only for Government Subscribers) 3 6 Politically Exposed Person Politically Exposed Persons’ (PEPs) are individuals who are or have been entrusted with prominent public functions in a foreign country, for example heads of state or of the government, senior politicians, senior government, judicial or military officials, senior executives of state- owned corporations, important political party officials. 4 7 Subscriber’s Bank Details For Tier I Tier II account, bank details are mandatory and it should be supported by a documentary proof. Please attach a cancelled cheque containing Subscriber Name, Bank Name, Bank Account Number and IFS Code. If cheque is not available or cheque is not preprinted with Subscriber name, a copy of bank passbook or bank statement or bank certificate or letter from Bank mentioning Subscriber Name, Bank Name, Bank Account No. and IFS Code should be submitted. 5 8 Subscriber’s Nomination Details Nomination details are mandatory. In case of more than one nominee, percentage share value for all the nominees must be integer. Decimals/ Fractional values shall not be accepted in the nomination(s). 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. 6 10 Pension Fund (PF) Selection and Investment Option Government employee/subscribers can exercise choice of Pension Funds and allocate their investments either in Asset Class‘G’ under’ Actice Choice’ and in Life Cycle Funds - LC 50 or LC 25 under ‘Auto Choice’. In case a Government employee/subscribers does not exercises the choices of Pension Fund, their contributions will be allocated among 03 Pension Funds namely (i) LIC Pension Fund Limited (ii) SBI Pension Funds Pvt. Limited (iii) UTI Retirement Solutions Ltd. 7 11 Declaration by subscriber on FATCA Compliance Clarification / Guidelines on filling details if applicant residence for tax purposes in jurisdiction(s) outside India • Jurisdiction(s) of Tax Residence: Since US taxes the global income of its citizen, every US citizen of whatever nationality, is also a resident for tax purpose in USA. • Tax identification Number (TIN): TIN need not be reported if it has not been issued by the jurisdiction. However, if the said jurisdiction has issued a high integrity number with an equivalent level of identification (a “Functional equivalent”), the same may be reported. Examples of that type of number for individual include, a social security/insurance number, citizen/personal identification/services code/number and resident registration number) • If applicant residence for tax purpose in jurisdiction(s) within India, Permanent Account Number (PAN) to be provided as Tax Identification Number (TIN) • In case applicant is declaring US person status as ‘No’ but his/her Country of Birth is US, document evidencing Relinquishment of Citizenship should be provided or reasons for not having relinquishment certificate is to be provided 8 12 Declaration by Subscriber Signature / Thumb impression should only be within the box provided in the form. Thumb impression, if used, should be attested by the designated officer of POP/POP-SP/Nodal office with the official seal and stamp. Left Thumb Impression in case of males and Right Thumb Impression in case of females. General Information for Subscribers a) The Subscriber can obtain the status of his/her application from CRA and their designated nodal officer. b) Subscribers are advised to retain the acknowledgement slip signed/ stamped by the designated nodal officer where they submit the application. c) For more information / clarifications, contact CRA: Website: https://www.npscra.nsdl.co.in Call: 022-4090 4242 Address: Central Recordkeeping Agency (CRA) Protean eGov Technologies Limited (formerly NSDL e-Governance Infrastructure Limited) 1st Floor, Times Tower, Kamala Mills Compound, Senapati Bapat Marg, Lower Parel (W), Mumbai - 400013
  • 22. Equity Allocation Matrix for Active Choice Age (years) Max. Equity Allocation Upto 50 75% 51 72.50% 52 70% 53 67.50% 54 65% 55 62.50% 56 60% 57 57.50% 58 55% 59 52.50% 60 above 50% Please note: 1. Upto 50 years of age, the maximum permitted Equity Investment is 75% of the total asset allocation. 2. From 51 years and above, maximum permitted Equity Investment will be as per the equity allocation matrix provided above. The tapering off of equity allocation will be carried out as per the matrix on date of birth. Annexure A to CSRF Ver 1.5
  • 23. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH Page 1 of 2 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
  • 24. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH Page 2 of 2 FORM–2 Details of Family [See Rules 10 (3)] Important 1. The original Form submitted by the Government servant is to be retained. All additions/alterations are to be communicated by the Government servant/retired Government servant/Subscriber along with the supporting documents and the changes shall be recorded in this Form under the signature of Head of Office in column (7). No new Form will substitute the original Form. However, the retiring subscriber should submit the details of family afresh at the time of retirement. 2. The details of spouse, all children and parents (whether eligible for family pension or not) and disabled siblings (brothers and sisters) may be given. 3. The Head of Office shall indicate the date of receipt of communication regarding addition or alteration in the family in the ‘Remarks’ column. The fact regarding disability or change or marital status of a family member should also be included in the ‘Remarks’ column. 4. Wife and husband shall include judicially separated wife and husband. 5. The retired Government Servant shall attach the details of change in family structure after retirement in the proforma prescribed under Dept. of PPW, OM No.1(23)-PP.W/91-E dated 04/11/1992. 6. Copies of birth certificates to be attached. Copies of any other relevant certificates, if available, should be attached. Name of the Govt. servant Designation Nationality Details of family members: S. No. Name Date of birth (DD/MM/YYYY) Aadhaar no.* (voluntary) Relationship with Govt. servant/retired Govt. servant Marital status Remarks Dated signature of Head of Office 1 2 3 4 5 6 7 1. 2. 3. 4. 5. 6. 7. I hereby undertake to keep the above particulars up to date by notifying to the Head of Office any addition or alteration. Email: (Optional) Place: Mobile: Date: (Signature) * Providing Aadhaar No. is voluntary. However, if it is provided, consent to link it to Bank Account and also for authentication of identity from UIDAI for pension related purpose only, is presumed.
  • 25. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH 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 and addresses of nominee/nominees Relationship with the Govt. Servant Age * Share of amount to be paid to each Contingencies on the happening of which the nomination shall become invalid Name, address, relationship of persons, if any, to whom the right of the nominee shall pass in the event of the 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.
  • 26. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH 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)
  • 27. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH Page | 1 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: _______________________
  • 28. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH Page | 2 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. Sl. No. Description Name and address of Company, Bank etc. Amount If not in own name, name and address of person in whose name held and his/her relationship with the PGIMER employee Annual Income derived Remarks 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) Sl. No. Description of items Price or value at the time of acquisition and/or the total payments made up to the date of return, as the case may be in case of articles purchased on hire purchase or installment basis If not in own name, name and address of the person in whose name and his/her relationship with the PGIMER employee How acquired with approximate date of acquisition Remarks 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.
  • 29. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH Page | 3 FORM No. IV Statement of Provident Fund and Life Insurance Policy on First Appointment (recruited in 20___ calendar year) Insurance Policies Sl. No. Policy No. and date of Policy Name of Insurance Company Sum insured / date of maturity Amount of annual premium 1 2 3 4 5 Provident Fund Type of Provident Funds/GPF/CPF/ NPS Account No. Closing balance as last reported by the Audit/Accounts officer along with date of such balance Contribution made subsequently Total Remarks (if there is dispute regarding closing balance, the figures according to the PGIMER employee should also be 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) Sl. No. Amount Name and address of Creditor Date of incurring Liability Details of Transaction Remarks 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).
  • 30.
  • 31.
  • 32. THROUGHPROPERCHANNEL 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 26.09.1998 and PG/MA/2000/19831-914, dated 20.04.2000, on the subject noted above, I am to certify as under: That I am working as . in the Deptt. of PGIMER, Chandigarhsince getting Basic Payof 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 _date (Certificate from Transport Office enclosed). to That I have not remain absent from duty for the period exceeding 30 days due to tour etc. during the to period August 1997 to April 2000 except for the period from_ In view of the above, I may kindly be granted Transport Allowance sanctioned by the Government of India, Ministry of Finance, Department of vide O.M. No. 21(1) 97/EW(B), dated 3 October-1997. Thanking you. Yours faithfully, Name: Designation: -_ Emp. Code No_ Deptt. Forwarded to the Financial Adviser, PGIMER, Chandigarh for necessary action. HEAD OF THE DEPTT. Certified by TransportDepartment has availed/not Certified that Mr./Ms_ to availed/Not availing PGI staff Bus facility since Sr. Technical Officer (Vehicles), Transport Deptt. PGIMER, Chandigarh.
  • 33.
  • 34. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH 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 Is Differently abled Percentage of Differently abled Type of Differently 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 State Thana Nearest Railway 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 Name Year of Birth Birth Place Sex Relation Marital Status Is Dependent Dependent Upto Dependent Occupation Details Dependent Present Address GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration Gratuity Gratuity Percentage Gratuity Declaration Family Member Name Year of Birth Birth Place Sex Relation Marital Status Is Dependent Dependent Upto Dependent Occupation Details Dependent Present Address GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration Gratuity Gratuity Percentage Gratuity Declaration Family Member Name Year of Birth Birth Place Sex Relation Marital Status Is Dependent Dependent Upto Dependent Occupation Details
  • 35. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH Dependent Present Address GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration Gratuity Gratuity Percentage Gratuity Declaration Family Member Name Year of Birth Birth Place Sex Relation Marital Status Is Dependent Dependent Upto Dependent Occupation Details Dependent Present Address GPF/EPF Status GPF/EPF Percentage GPF/EPF Declaration Gratuity Gratuity Percentage Gratuity Declaration Family Member Name Year of Birth Birth Place Sex Relation Marital Status Is Dependent Dependent Upto Dependent 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 To Date Source of Recruitment Service Group Cadre Appointment Date Joining Date Retirement Date Designation Department Pay Scale Category Pay Scale Type Pay Band Pay Scale Grade Pay Pay Scale Effective Date Basic Pay Basic Effective Date Consolidated Salary Consolidated Salary Effective Date Seniority No. Seniority Date Next increment Date Current Status QUALIFICATION DETAILS Serial No. Examination Degree University/Board Subject Year of Passing Percentage%
  • 36. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH 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) _______________________________________________
  • 37. LukrdksÙkj fpfdRlk f'k{kk ,oa vuqla/kku laLFkku] p.Mhx+ POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION RESEARCH, CHANDIGARH 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___________________________
  • 38. 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) members Date of Birth/Age Sex Relationship Occupation/Income/ 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. Affix passport size group photo
  • 39. 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.
  • 40. 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.
  • 41. 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
  • 42. 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)