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Fcunq Fooj.K Target Achiveme NT: Annexure-S1

1) The document appears to be a form to request the allotment of a permanent retirement account number and provides sections to fill in personal details, employment details, and nomination details. 2) Section A requests the subscriber to provide personal information such as name, gender, date of birth, address, phone number, email, bank details. Section B is to be filled and verified by the designated office to provide employment details. 3) Section C allows the subscriber to nominate up to 3 individuals and provide their names and relationship to the subscriber.

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55 views6 pages

Fcunq Fooj.K Target Achiveme NT: Annexure-S1

1) The document appears to be a form to request the allotment of a permanent retirement account number and provides sections to fill in personal details, employment details, and nomination details. 2) Section A requests the subscriber to provide personal information such as name, gender, date of birth, address, phone number, email, bank details. Section B is to be filled and verified by the designated office to provide employment details. 3) Section C allows the subscriber to nominate up to 3 individuals and provide their names and relationship to the subscriber.

Uploaded by

Teena
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 6

Annexure-S1

Page 1

To affix recent
Coloured
photograph
(3.5cm x 2.5
cm)


Transfarmer

( )

fcUnq fooj.k

Target

Achivem
nt

Annexure-S1
Page 2
Sir/Madam,
I hereby request that a permanent retirement account number be allotted to me.
I give below necessary particulars :

Section A - Subscribers Personal Details ( * Indicates Mandatory Field)

1.

Full Name (Full expanded name: initials are not permitted)


Please Tick as applicable,
Shri
Smt.
Kumari

First Name*
Middle Name
Last Name
2. Gender * Please Tick as applicable,

Male

Female

vr% ekuuh;k eq[;ea=h egksn;k ls fuosnu gS fd mDr iapk;rh


jkt HkrhZ izfdz;k dks iqu% izkjEHk dj vfrkh?kz ujsxk dkfeZdks ds
lkFk gh jkT; ds 27000 uo;qodks dks fu;qfDr fnykus dk ekxZ izkLr
djkus dk Je djkosA /kU;okn

3. Date of Birth *
D

D M M Y Y Y Y

4. PAN
(Date of Birth to be certified by DDO

5. Fathers Full Name:


First Name*
Middle Name

Last Name
6.Present Address:
Flat/Unit No, Block no.*
Name of Premise/Building/Village

Area/Locality/Taluka

District/Town/City *

State/Union Territory *

Country *

Pin Code *
7.Permanent Address: If same as above, Please Tick

else,

Annexure-S1
Page 3
Flat/Unit No, Block no.*

Name of Premise/Building/Village

Area/Locality/Taluka

District/Town/City *

State/Union Territory *

Country *

Pin Code *
8. Phone No. *
STD Code
9. Mobile No. *

Phone No

Annexure-S1
Page 4
10. Email ID

11. Subscribers Bank Details (Please refer instruction no. 4)

Savings A/c

Current A/c

Bank A/c Number


Bank Name

Bank Branch

Bank Address

Pin Code *
Bank MICR Code

(Wherever applicable)

12. Value Added Services:

i) SMS Alert:

Yes

No

ii) Email Alert:

Yes

No

I ----------------------------------, the applicant, do hereby declare that what is stated above is true to the best of my
information & belief.
Date :
D D M M Y Y Y Y

Signature/Left Thumb
Impression of Subscriber

Section B - Subscribers Employment Details to be filled and attested by DDO (All Details are Mandatory)
1. Date of Joining

2. Date of Retirement
D

D M M Y Y Y Y

D D M M Y Y Y

3. PPAN
4. Group of the Employee (Please Tick)

(Please refer to instructions No. 5)


Group A

Group B

Group C

Group D

5. Office
6. Department

7. Ministry

8. DDO Registration Number

9. PAO/CDDO Registration Number


(Please refer to instructions No. 6.)

10. Basic Salary


11. Pay Scale

Annexure-S1
Page 5
Certified that the above declaration has been signed / thumb impressed before me by ---------------------------------after he / she has read the
entries / entries have been read over to him / her by me and got confirmed by him / her. Also certified that the date of birth and employment
details is as per employee records available with the Department.

Rubber Stamp of the DDO


Signature of the Authorised Person
Designation of the Authorised Person :
Date :
D D M M Y Y Y Y

Name of the DDO :


Department/Ministry:

Annexure-S1
Page 6
Section C - Subscribers Nomination Details (* Indicates Mandatory Field for nominee)
1. Name of the Nominee *:
1st Nominee

2nd Nominee

3rd Nominee

First Name *

First Name *

First Name *

Middle Name

Middle Name

Middle Name

Last Name

Last Name

Last Name

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


1st Nominee
3. Relationship with the Nominee*
1st Nominee

2nd Nominee

3rd Nominee

2nd Nominee

3rd Nominee

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