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Appendix - A

APPLICATION FOR COMPASSIONATE GROUND APPOINTMENT

PART-A

l. (a) Number, Rank and Name of the Government :

Servant (Deceased/Retired on medical ground / Missing)

(b) Unit last Served

(c) Designation of the Govt servant

(d) Date of Appointment

(e) Date of Birth of the Govt Servant

(0 Date of Death (if while in service)

(g) Date of Retirement on medical Ground

(h) Total Length of service rendered

0) Whether permanent or temporary

(k) Whether belonging to SC/ST/OBC

ll. (a) Name of the Candidate for appointment

(b) His/Her relationship with the Govt servant

(c) Date of Birth

(d) Educational Qualifications

(e) Whether any other dependent family memberhas been appointed on compassionate ground

(0 Home Address.

(i) Village

(ii) Po

(iii) Tehsil

(iv) District

(v) PIN

(vi) State

(vii) Mobile/Phone No and Email lD :

Post for which applied for :

,f'ffi*;w#i, Contd....2l-

(

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2

lll. Particulars of Total Assets Left includinq Amount of

(a) Family pension

(b) DCR gratuity

(c) GPF balance

(d) Life lnsurance policies(including Postal Life lnsurance)

(e) Moveable and immovable properties

and annual income earned wherefromby the family

(0 ARGIS insurance amount

(g) Encashment of leave

(h) Any other assets

Total

lV. Brief particulars of liabilities if any

V. Particulars of all dependent family membersof the Govt servant (is some are employed, thereincome and whether they are livingtogether or separately)

SerNo

Name (s) Relationshipwith the GovtServant

Age Address Employed or not(if employ)

(1) (2) (3) (4) (5) (6)

Signature of the Candidate

Name

Address

Dated: _2021

Tele/Mob No.

Contd...3l

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,oaa

e

17

J

DECLARATION/U N DERTAKING

1. I hereby declare that the facts given by me above are, to the best of myknowledge, correct. lf any of the facts here in mentioned are found to be incorrect orfalse at a future date, my service may be terminated.

2. I hereby also declare that I shall maintain properly the other family members whowere dependent on the Government servanvmember of the Force as mentioned againstI (a) of Part-A of the application form and in case it is proved at any time that the saidfamily members are being neglected or terminated.

Dated: 2021 Signature of the Candidate

Name

Add ress

Tele/Mob No.

COUNTERSIGNED BY GAZETTED OFFICER/VILLAGE PRADHAN/ SARPANCH

(Seal and signature)

Dated:........... .... 2021

q,!20

.C

)., 18

4

SPECIMEN OF UNDERTAKING CERTIFICATE REGARDING DETAILS OFCOMPASSIONATE GROUND APPOINTMENT GRANTED TO

DEPENDENT FAMILY MEMBERS

1. I, Mr/Miss/Mrsson/daughter/wife of Ex No ............... .... RankName ........... ....... of Assam Rifles have beenapplied for Compassionate Ground Appointment rally for the year 2021 .

2. I hereby undertake and certify that the my following family members have already beengranted Compassionate Ground Appointment and serving Assam RiflesiRetired from AssamRifles:-

(a)

(b)

(c)

OR

(d) No one of my family member is appointed against Compassionate GroundAppointment as on date except me for which I have been applied for CompassionateGround Appointment rally for the year 2021

3. I further undertake that above information are true to the best of my knowledge. ln caseof above information's are found false at any time even at later stage, department will holdright to dismissed me from service any time with the decision of Assam Rifles Competentauthority, and I will refund the Govt expenses partly/wholly as deemed fit by theDepartmenVGovernment.

Signature of the candidate

Name :

Husband/Father's Name :

Place :

Date : 2021

Trade

viIPO

DiSt

State

Pin

COUNTERSIGNED BY GAZETTED OFFICER/VILLAGE PRADHAN/ SARPANCH

ffi-.r:. .-? It'i::t,.1 "s[;,,;q

Dated:........... .... 2021

(Seal and signature)