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Indian Institute of Science Education and Research BerhampurJoining Report

Dated: _________

The DirectorIISER Berhampur Berhampur - 760 010Ganjam District, Odisha

Dear Sir,

With reference to your appointment letter No. ………………….…….dated…,………I report myself on duty in the forenoon / afternoonof ……………………………………

I thank you once again for providing me the opportunity to serve the Institute. I will perform my duties sincerely, honestly and to the best of my abilities.

Yours sincerely,

(Signature)

Name: ……………………………………

Designation …………………………….

Department …………………………….

Date of birth ……………………………

Indian Institute of Science Education and Research BerhampurMEDICAL EXAMINATION REPORT

(To be issued by a Govt. Civil Surgeon/Medical Superintendent of Govt. Hospital)

PERSONAL HISTORY

1. Name........................................................................... 2. Designation……………………………………………………….3. PF No.......................................................................... 4. Parent / Guardian's Name........................................... 5. Date of Birth................................................................6. Gender……………………………………………………………..7. Identification Mark on the Body, If any.................................... (This can be a mole, scar or birthmark)8. Major illness / operation, if any.............................................. (Specify nature of illness / operation)

MEDICAL CERTIFICATE

(The following are to be filled by the Medical Officer Conducting the medical examination)

1. Height...................cm. 2. Weight.........................kg3. Past History 4. Chesta) Mental Disease...................... c) Inspiration...................cmb) Epileptic Fits......................... d) Expiration....................cm5. Blood Group.......................... 6. Hearing............................7. Vision with or without glassesa) Right Eye................................ b) Left Eye............................c) Colour Blindness....................8. Respiratory system................. 9. Nervous system................10. Heart …………………………….. 11. Abdomen …………………...a) Sounds................................... c) Liver..................................b) Murmur……………………………. d) Spleen...............................12. a) Hernia.............................. b) Hydrocele..........................13. Any other defects.............................................................................

Contd….2….

Photo to be attested by Medical Officer

(2)

Certified that Mr./Ms.________________________S/D of Shri ________________

a. Fulfills the prescribed standard or physical fitness and is FIT for job/duties at IISER Berhampur.

b. Does not fulfill the prescribed standard of physical fitness and is unfit/temporarily unfit for joining services/duties at IISER Berhampur.

Signature of the Medical Officer Signature of the Candidate(Minimum qualification MBBS/MD)

Full Name.....................................................

Medical Registration No................................

Address........................................................

….................................................................

Office Seal

Date.......................................

Indian Institute of Science Education and Research Berhampur

CHARACTER CERTIFICATE

Certified that I have known Mr./Ms./………………………………………

Son/daughter of Shri…..…………………………………………….for the

last………….years ……………….months. He/She bears a good moral

character and is of ………………….nationality. He/She is not related to

me.

Place: Signature

Date : ___________________________ Name (in Capital Letters)

Designation & Address with Stamp

This certificate should be from any one of the following:1. Gazetted Officer of Central or State Government;2. Members of Parliament or State Legislature belonging to the

constituency where the candidate or his parent/ guardian is ordinarily resident;

3. Sub-Divisional Magistrates/ Officers;4. Tehsildars or Naib/ Deputy Tehsildars authorized to exercise

magisterial powers;5. Principal/Head Master of the recognized School/ College/ Institution

where the candidate studied last;6. Block Development Officer;7. Post Masters;8. Panchayat Inspectors


Allegiance to the Constitution

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 without fear or favour, affection or ill-will and that I will uphold the Constitution and the laws.

Signature

Name____________________________

P.F.No. __________________________

Designation______________________

Department______________________


Oath of SecrecyDate: __________

I,........................................................................have been appointed as ……………………..……………..at IISER Berhampur, do swear in the name of God/solemnly affirm that I will bear true faith and allegiance to the Official Secrets Act/Statutes and Central Civil Services (CCS) Conduct rules, 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 or reveal to any person any matter which shall be brought under my consideration.

Signature

Name____________________________

P.F.No. __________________________

Designation______________________

Department______________________


Dated: ________

Subject: Declaration regarding bigamous marriage

I hereby declare that I have not entered into or contracted a marriage with a person having a spouse living, or who, having a spouse living, have not entered into or contracted a marriage with me.

Signature _______________________

Name____________________________

P.F.No. __________________________

Designation______________________

Department______________________

Indian Institute of Science Education and Research

Berhampur

FORMHOME TOWN DECLARATION

[ OM No. 43/15/57-Estts. (A) dated 24-6-1958]

I, ___________________________hereby declare that my home town is at the place as shown below for the purpose of availing Leave Travel Concession for self and family as notified in the Govt. of India, Ministry of Home Affairs, New Delhi O.M. No.43/1/55/Estts - (A) Part-II dated 11-1-1956.

Home Town/Place of visit

Nearest Rly Station

District/Town & State

Remarks

_______________________Signature

Name____________________________

P.F.No. __________________________

Designation______________________

Department______________________

Countersigned by____________________

Head of Office

Indian Institute of Science Education and Research BerhampurDate:

Declaration on Dependent Family Members(1) Personal Details:

1 Name

2 Designation

3 Date of Birth

4 PF No.

5 Date of appointment

(2) Details of the Dependent Family Members:S. No.

Name (s) of the member(s) of the

family*

Date of Birth

Ageas on date

Relationship

Marital Status

Please mention the category : (a) Employed (b) Pensioner (c) Family

Pensioner (d) Others

Personal Annual Income of the

dependent

1

2

3

4

5

(*) (i) I hereby undertake to keep the above particulars up-to-date by notifying to the Head of Office any addition or alteration.

(ii) Family for this purpose means family as defined in Clause (b) of sub-rule (14) of Rule 54 of the CCS (Pension) Rules, 1972.[http://persmin.gov.in/pension/rules/pencomp7.htm#Family_Pension,_1964]

(iii) Wife and husband shall include respectively judicially separated wife and husband.(iv) A self-certified proof of Date of Birth is enclosed in respect of dependent Brothers/Sisters, if any.

Signature of the employee

(3) For the use of controlling unit/office of the HOD

Forwarded

Section/Unit I/C

Recommended

HOD

(4) Administrative Approvals:Checked

Dealing Assistant

Verified & submitted for approval

Assistant Registrar (Admin.)

Approved as per rules

DOFA/Registrar/Director


The DirectorIISER Berhampur

DECLARATION

I, ……………………………………………………………………. son/daughter of Shri……………..……………………………………… resident of village/ town/ city ………………………district …………….…….…… State …………..……………………… hereby declare that I belong to the …………………….……………….. Community, which is recognized as a backward class by the Government of India for the purpose of reservation in services as per orders contained in Department of Personnel and Training Office Memorandum No. 36012/22/93-Estt.(SCT), dated 08.09.1993. It is also declared that I do not belong to persons/ sections (Creamy Layer) mentioned in Column 3 of the Schedule to the above-referred Office Memorandum, dated 08.09.1993.

____________________________

Date: ___________________________ Signature of the candidateName & permanent

address

…………………………………..

…………………………………..

…………………………………..

(Note: To be filled only by OBC category)


Date: _________________DECLARATION

I, ……………………………………………………………………………. son/daughter of Shri……………..………………………resident of village/town/city ……………………district …………….…….…… State …………..……………………… hereby declare that my spouse is employed/not employed in Government Service, and she/he is not availing the following facilities for herself/himself or for any of the family members from the parent department/Institute working for. I read the enclosed provisions made in the Government Orders (printed overleaf) in this regard and undertake to inform the Institute as and when there is any change in the status of employment of my spouse in respect of the following conditions.

1) Medical Attendance/Treatment2) House Building Advance3) Children’s Educational Assistance 4) Family Planning Special Increment5) Leave Travel Concession6) Traveling Allowance7) Family Pension 8) House Rent Allowance, if residing in Govt. Quarters 9) Central Government Health Scheme 10) Allotment of Residence

The relevant rules as summarized in the enclosure (appended overleaf) are read and certified that the same will be complied from time to time. I/we understand that any violation will attract legal proceedings and penal provision as per Govt. rules. Signature of Spouse, if employed elsewhere in Govt. establishments.

Signature of Employee

Name NameP.F.No. P.F.No.Designation Designatio

n Department Departmen

t

Address Address

EMPLOYEE DATA SHEET

P.F. No. _____________

IISER Berhampur

1. Name in Full (First Surname)

Married Single Male Female

2. Mother’s Name (First Surname)

3. Father’s Name (First Surname)

4. Present Address (for Communication)

PIN

5. Permanent Address

PIN

FaxE-mailTelephone Office: Residence:Mobile

Day Month Year

6. Date of Birth 7(a). Nationality:

7. (b) Category: SC ST OBC Gen

8. Academic Record starting with Secondary Education:

Examination Branch/ Specialization

College/University/Institute Year % of Marks/ Grade

Division

9. Professional Experience Record:Name of Institution / University Position Held Date of Joining Date of Leaving

Affix stamp size photograph

10. Please provide your family details (dependents only)S. No. Name Date of

BirthRelationship Present

occupation

DECLARATION

I, _____________________________________________ hereby, declare that all entries in this

form are true to the best of my knowledge and belief.

Date:

(Signature of the employee)

Place:

FORM-III

LETTER OF ADMISSION AND AUTHORITY

Date: __________

To,

__________________

__________________

__________________

Dear Sir,

Re: Group Savings-Linked Insurance Scheme

I wish to join Group Saving-Linked Insurance Scheme arranged with the Life Insurance

Corporation of India and request you to admit me as an Insured Member of the Scheme with

effect form _____________ . I hereby authorize you to deduct a sum of Rs.__________ as

contribution towards the scheme from my salary starting from the salary for the month of

___.

I further agree that this letter of authority shall not be revoked by me so long as I am a

regular employee. My date of birth, as recorded in ________________ Certificate sent

herewith, is ___________.

.

Yours Faithfully,

_____________

(SIGNATURE)

Name:_____________________________

(In Block Letters)

Badge No. or Salary Roll no. or Membership No._____________________

Designation :_________________________________________________

Department & Office:___________________________________________

FORM – IV

FORM OF APPOINTMENT OF BENEFICIARY

I, ____________________________________________________________________

An Insured Member of the ________________________________________________

___________________Group Saving-Linked Insurance Scheme hereby appoint in terms of

Rule No.13 headed ‘Appointment of Beneficiary’ of the Rules governing the Scheme my

(relationship)______________ named _______________________________ and whose

address is __________________________________________

________________________________________________________

________________________________________________________

as the person to be the beneficiary to whom the moneys payable in terms of the Rules of the

Scheme shall be paid in the event of my death.

Signed at _______________ this __________________day

Of _____________________199_____________.

Signature of Insured Member

Witnessed by :

1) i) Signature _____________

ii) Name ________________

iii) Address _________________________________________________________

_________________________________________________________

2) i) Signature______________

ii) Name ________________

iii) Address _________________________________________________________

_________________________________________________________

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ATTESTATION FORM WARNING

1. 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 candidateunfit for employment under the Government/Institute.

2. If detained, convicted, debarred etc subsequent to the completion and submission of the form, the details should be communicated immediately to the Director, IISER Berhampur, failing which it will be deemed to be a suppression of factual information.

3. If the fact that false information has been furnished, or that there has been suppression of any factual information in the attestation comes to notice at any time during the service of a person, his/ her services would be liable to be terminated.

1. Name in full (in block capitals) with aliases, if any. (Please indicate if you have added or dropped at any stage any part of your name or surname).

SURNAME NAME

2. Present address in full (i.e. Village, Thana and District, or House Number, Lane/ Street/ Road and Town)3(a). Home address in full (i.e. Village, Thana and District, or House Number, Lane/ Street/ Road and Town)3(b). If originally a resident of Pakistan, the address in that Country and the date of migration to Indian Union

4. Particulars of places (with periods of residences) where you have resided for more than one year at a 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 18 years should be given.

From ToResidential address in full

(i.e. Village Thana and District, orHouse Number, Lane/Street/Road and

Town)

Name of the District Head-quarters of the Place mentioned in

the preceding column.

Affix a Passport Size coloured Photograph

(5x7 cms)

NAME

Nationality(By birth & or by domicile)

Place of birth

Occupation (if

employed, give

designation & official address)

Present postal

address (if not

alive, give last

address)

Permanent Home Address

1 2 3 4 5 6(i) Father (name

with full aliases, if any)

(ii) Mother

(iii) Wife/Husband

(iv) Brother(s)

(v) Sisters(s)

(vi) Children

5. Information to be furnished with regard to son(s) and daughter(s) in case they are studying / living in a foreign country.

Name Nationality (By birth and/ or by

domicile)

Place of Birth

Country in which

Studying/living with full address

Date from which studying/ living in the country mentioned in

previous column.

1 2 3 4 5

6. Nationality: ______________________7(a) Date of Birth

7(b) Present age

7(c) Age at Matriculation/ High School/ Higher Secondary/SSLC

8(a) Place of birth, District and State in which situated

8(b) District and State to which you belong

8(c) District and State to which your father originally belonged:

9 (a) Your religion

9(b) Are you a member of a Scheduled Caste/ Scheduled Tribe/ OBC? Answer 'Yes' or 'No' and if the answer is 'Yes' state the name thereof

10. Educational Qualification showing place of Education with years in Schools & Colleges (Matriculation onward)

Name of School/ College with full address

Date of entering

Date of leaving

Examination Passed

11. (A) Are you holding or have at any time held an appointment under the Central or State Government or 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 date of employment up to date.

Period Designation, emoluments &

nature of employment

Full Name & address of employers

Reasons for leaving previous serviceFrom To

11 (B) Please state,

(i)If the previous employment was under the Govt. of India, a State Govt./ an undertaking owned or controlled by the Govt. of India or a State Govt./ an autonomous body/ University/ Local body?

(ii)If you had left the service on giving one month's notice under rule 5 of the Central Civil Services (Temporary Service) Rule 1965, or any similar corresponding rules?

(iii) If any disciplinary proceeding was framed against you?

(iv)If you were called upon to explain your conduct in any matter at the time you were given the notice of termination of service or at a subsequent date, before your services were actually terminated?

12 (i) (a) Have you ever been arrested? Yes/No(b) Have you ever been prosecuted? Yes/No(c) Have you ever been kept under detention? Yes/No(d) Have you ever been bound down? Yes/No(e) Have you ever been fined by a court of law? Yes/No(f) Have you ever been convicted by a court of law for

any offence? Yes/No(g) Have you ever been debarred from any examination or

Rusticated by any University or any other educational authority/ institution? Yes/No

(h) Have you ever been debarred/ disqualified by any Public Service Commission from appearing at its examination/selection? Yes/No

(i) Is any case pending against you in any court of law at the time of filling up this Attestation Form? Yes/No

(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? Yes/No

(i) If the answer to any of the above mentioned questions is 'Yes' give full particulars of the /fine/conviction/sentence/punishment etc. and/ or the nature of the case pending in university/educational authority etc. at the time of filling up this form.

Note: (i) Please also see the 'warning' at the top of this Attestation Form(ii) Specific answer to each of the questions should be given by

striking out 'Yes' or 'No', as the case may be.

13. Name & address of two responsible persons of your locality or two referees to whom you are known.

1.

2.

I certify that the foregoing information is correct and complete to the best of my knowledge and belief. I am not aware of any circumstances, which might impair my fitness for employment under Government/ Institute.

Signature of Candidate.............................Date: Designation..............................................Place.............. Department/Section.................................


New Pension Scheme

Annexure-I

(Details to be furnished by the Government servant)

Name of the Government servant(in Block Letters)

:

Designation :

Name of Ministry/Deptt./Organization :

Scale of Pay :

Date of Birth :

Date of joining Government service :

Basic Pay :

Nominee for accumulations the Pension Account :

S No.

Name of nominee (s) Age Date of Birth

Percentage of share of payable

Relationship with the Government

servant (1) (2) (3) (4) (5)1. 2.3.4.

Signature of the Government servant

Registrar/DOFA

letter of admission and authority - … forms for regular... · web viewi ., do swear in the name...

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