fpfdrlk chek ds lecu/k esa dehz ,oa vkfjrksa dk foojpurvanchalbank.com/news/pgb_160120121254.pdf ·...
TRANSCRIPT
ANNEXURE- 24
cSad esa fu;qfDr ds fy, vkSipkfjdrk iw.kZ djus gsrq ANNEXURE 01 ls ANNEXURE 23
dh lwph
¼1½ fu;qfDr Kkiu i=
¼1A½ dehZ ds LFkk;h ,oa i=kpkj irk dk fooj.k A
¼2½ cSad esa fu;qfDr lEcU/kh ?kks’k.kk i= A
¼3½ lsok fofu;e ¼deZpkjh vkSj vf/kdkjh½ 2010 ls vkc) gksus dh ?kks’k.kk A
¼4½ drZO; fu’Bk ,oa xksiuh;rk dh ?kks’k.kk A
¼5½ vU; fiNM+k oxZ ,oa Øheh ys;j lEcU/kh ?kks’k.kk i= A
¼6½ izfrHkwfr jkf”k ij xzg.kkf/kdkj vafdr djus dk vf/kdkj i= A
¼7½ fu;qfDr iwoZ vU;= vkosnu djus dh ?kks’k.kk A
¼8½ fnokfy;k u gksus dh ?kks’k.kk A
¼9½ vf/kokl ?kks’k.kk i= A
¼10½ cSad esa fu;qfDr iwoZ vU;= dk;Zjr u jgus lEcU/kh ?kks’k.kk i= A
¼11½ oSokfgd fLFkfr ,oa ifjokj ds vkfJr lnL;ksa ds lEcU/k esa ?kks’k.kk i= A
¼12½ funsZ”kh ukekdau A
¼13½ cpr ;qDRk lewg chek ;kstuk dh lnL;rk gsrq vkosnu i= o ukekadu i= A
¼14½ FORM – F Nomination ¼xzsP;qVh ukekadu i=½ (दो परतियो म ) ¼15½ Hkfo’; fuf/k ukekadu i= A
¼16½ Employee details for Provident Fund & Pension
(17) fpfdRlk chek ds lEcU/k esa dehZ ,oa vkfJrksa dk fooj.kA
¼18½ vkfLr;ksa ,oa nkf;Roksa dk fooj.k A
¼19½ ifjp; i= gsrq fooj.k A
¼20½ Specimen Signature
¼21½ cSad fpfdRld }kjk tkjh LokLF; izek.k i= (परारप )A ¼22½ nks izfrf’Br O;fDr;ksa @in /kkfj;ksa ls vkpj.k izek.k i= A
¼23½ LVSEi ;qDr uksVjh izek.k i= A
UUUUUUUUUUUUUUUU
ANNEXURE- 01
fu;qfDr Kkiu i=
ikliksVZ lkbt
QksVks
dehZ dk uke % Jh---------------------------------------------------
firk dk uke % Jh---------------------------------------------------
deZpkjh dh tUe frfFk % --------------------------------------------------------
“kS{kf.kd ;ksX;rk % --------------------------------------------------------
--------------------------------------------------------
izFke fu;qfDr % vf/kdkjh Ldsy&II fnukad--------------------------------
osrueku . Rs. 31705-1145/1-32850-1310/10-45950-1310/2-48570-1460/2-51490
“krZ % ifjoh{k.k dky 02 o’kZ
funsZ”kh % ¼1½ Jh---------------------------------------------------------------------------
uke] in ,oa irk % ------------------------------------------------------------------------------
पिन कोड:-
¼2½ Jh---------------------------------------------------------------------------
-------------------------------------------------------------------------
पिन कोड:- fpfdRlk fjiksVZ % lUrks’ktud@izkIr fd;k
fu’Bk ,oa xksiuh;rk ?kks’k.kk i= % izkIr fd;k
fu;qfDr lEcU/kh ?kks’k.kk i= % izkIr fd;k
cSad esa dk;Zjr lEcfU/k;ksa dk fooj.k% -----------------------------------------------------
-----------------------------------------------------
deZpkjh dk LFkkbZ irk % xzke@eqgYyk------------------------------iksLV----------------------
fodkl [k.M---------------------------------rglhy--------------
Fkkuk---------------------------------------------- ftyk---------------------------------
vks-ch-lh-@vuqlwfpr tkfr@tutkfr % -----------------------------------------------------------------
dkfeZd dk gLrk{kj %
Signed in presence of A.G.M. (Personnel)
lgk;d egkizcU/kd ¼dkfeZd½
Annexure 24 ds vuqlkj layXud izkIr dj bl dk;kZy; esa fjdkMZ fd;k x;k A
iwokZapy cSad]
iz/kku dk;kZy;]rkjke.My]xksj[kiqj
fnukad %------------------------------------- lgk;d egkizcU/kd ¼dkfeZd½
v/;{k
ANNEXURE-1(A)
deZpkjh dk uke % Jh@dq0@Jherh------------------------------------------------------------------
firk@ifr dk uke % Jh---------------------------------------------------------------------------------------------
tUe frfFk % -------------------------------------------------------------------------------------------------
laoxZ@tkfr % -------------------------------------------------------------------------------------------------
LFkku% xksj[kiqj gLrk{kj%
frfFk% iwjk uke%
in % vf/kdkjh Ldsy&II
fnukad%---------------------------------------
LFkk;h irk i=kpkj irk
xzke@eksgYyk % xzke@eksgYyk %
iksLV % iksLV %
fodkl [k.M % fodkl [k.M %
rglhy % rglhy %
Fkkuk % Fkkuk %
ftyk % ftyk %
fiu dksM % fiu dksM %
jkT; % jkT; %
ANNEXURE-02
lsok esa]
v/;{k]
iwokZapy cSad]
iz/kku dk;kZy;] rkjke.My
xksj[kiqj
egksn;]
cSad esa fu;qfDr lEcU/kh ?kks’k.kk & i=
eSa ------------------------------------------------------------------- iq=@iq=h@iRuh Jh ----------------------------------------------------------- ,rn~}kjk iqf’V
djrk@djrh gWw fd esjh fu;qfDr ls lEcfU/kr tks lwpuk,a] fooj.k esjs }kjk izLrqr fd;s x;s esjs vkosnu
[email protected] i=@tkfr izek.k i= esa] esjh mez] “kSf{kd ;ksX;rk] tkfr bR;kfn ds lEcU/k esa gSa] og esjh
tkudkjh ds vuqlkj lR; gSA
2& ;fn mijksDr lEcfU/kr [email protected] dh dksbZ vlR;rk esjh fu;qfDr ds mijkUr izdk”k esa vkrh gS rks
cSad bls xEHkhj dnkpkj (Serious Misconduct) eku ldrk gS vkSj eSa fcuk fdlh “krZ ds] cSad }kjk
ifjfLFkfr;ksa ds vuq:i fu/kkZfjr n.M] ftlesa ukSdjh ls c[kkZLrxh lfEefyr gS] dks ekuus dks ck/;
gksšxk@gksšxhA
LFkku % xksj[kiqj gLrk{kj %
frfFk %------------------------------------ iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
xokg % 1&
2&
ANNEXURE-03
lsok fofu;e ¼vf/kdkjh vkSj deZpkjh½ 2010 }kjk vkc) gksus dh ?kks’k.kk
eSa ,rn~}kjk ?kks’k.kk djrk g¡w@djrh g¡w fd eSus iwokZapy cSad ¼vf/kdkfj;ksa ,oa deZpkfj;ksa ½ lsok fofu;e] 2010
dks i<+ ,oa le> fy;k gS vkSj blls lger gksrs gq, mDr fofu;ekas ls vkc) gksus ds fy, eSa djkj djrk
g¡w@djrh g¡w rFkk bl lsok fu;ekoyh dh ,d izfr fu/kkZfjr izk:i ij izkIr djus dh ikorh nsrk g¡w@nsrh g¡w A
iwjk uke %
fu;qfDr in % vf/kdkjh Ldsy& II
fu;qfDr dh frfFk%
layXud@ikorh i= mijksDrkuqlkj gLrk{kj %
lk{kh %
frfFk %
LFkku% xksj[kiqj
ANNEXURE-04
drZO; fu’Bk ,oa xksiuh;rk dh ?kks’k.kk
eSa ---------------------------------------------------------------- ,rn~}kjk ?kks’k.kk djrk g¡w@ djrh g¡w fd eSa iwjh fo”oluh;rk ,oa
bZekunkjh ds lkFk vius lkeF;Z ,oa ;ksX;rk ds vuq:i iwokZapy cSad dh lsok esa vf/kdkjh@deZpkjh ds :i esa
dk;Z d:¡xk@d:¡xh tks esjs in@fLFkfr ds vuqlkj iwokZapy cSad ls lEcfU/kr gksxkA
eSa ;g Hkh ?kks’k.kk djrk g¡w@djrh g¡w fd cSad ds dk;Zdyki ds lEcU/k esa fdlh Hkh tkudkjh dks
fcYdqy xksiuh; j[kw¡xk@j[k¡wxh rFkk fdlh O;fDr ;k fdUgha O;fDr;ksa dks ;k cSad ds lkFk O;ogkj djus okys
fdlh O;fDr dks izR;{k ;k vizR;{k :i ls izdV ugha d:¡xk@d:¡axh@ gksus n¡wxk@gksus nw¡xhA tc rd fd eq>s
fdlh U;kf;d izkf/kdkjh }kjk ,slk djus dks ck/; ugha fd;k tk;s ;k cSad }kjk eq>s vius drZO;ksa ds fuoZgu esa
,slk djus dk funsZ”k u fn;k tk;A
LFkku % xksj[kiqj gLrk{kj %
frfFk %------------------------------------ iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
ANNEXURE-05
DECLARATION
Declaration Regarding community and ‘non-creamy layer’ status of OBC candidates. Insupport of Caste Certificate issued by an authority mentioned in Department of Personnel and
Training Office Memorandum No. 36012/22/93-Estt.(SCT) dated 15.11.1993
“I,.......................................................son/daughter
of Shri.................................................
Vill/Moh./H.No. ..................................
. .......................................
P.O........................................................
Tehsil.....................................................
Police Station..........................................
District.............................Pin Code..........
State......................................................
hereby declare that I belong to the_____________ community which is recognized as a
backward class by the Government of India for 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 8.9.1993”
SIGNATURE
POST :OFFICER SCALE- II
PLACE:
DATE:
ANNEXURE-06
lsok esa]
v/;{k]
iwokZapy cSad]
iz/kku dk;kZy;]rkjke.My
xksj[kiqj
egksn;]
izfrHkwfr jkf”k ls lEcfU/kr ?kks’k.kk
iwokZapy cSad }kjk eq>s vf/kdkjh Ldsy& II in ij nks o’kZ ds ifjoh{k.k dky esa fu;qDr fd;s tkus ds Øe esa eSa
opu nsrk g¡w@nsrh g¡w fd eSa cSad dh U;wure rhu o’kksZ rd lsok d:¡xk@d:¡xhA esjs }kjk fu/kkZfjr U;wure rhu
o’kksZ dh mijksDr cSad dh lsok iw.kZ fd;s tkus ds iwoZ cSad dh lsok NksM+us dh n”kk esa] eSa iwokZapy cSad] xksj[kiqj
esa tek esjh izfrHkwfr jkf”k :- 5000@&¼:i;s ik¡p gtkj ek=½ ds tCr fd;s tkus ls lger g¡wA lkFk gh eSa
2]00]000@¾ ¼:i;s nks yk[k ek=½ dh {kfriwfrZ Hkh tek d:¡xk@d:¡xh A
LFkku % xksj[kiqj gLrk{kj %
frfFk %------------------------------------ iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
ANNEXURE-07
lsok esa]
v/;{k]
iwokZapy cSad]
iz/kku dk;kZy;]rkjke.My
xksj[kiqj
egksn;]
eSa ?kks’k.kk djrk@djrh g¡w fd iwokZapy cSad esa vf/kdkjh Ldsy& II in ij fu;qfDr ls iwoZ eSus ftu foHkkxksa @inksa
ij fu;qfDr @fu;qfDr;ksa ds fy, vkosnu fd;k gS] mudk fooj.k fuEuor~ gS %&
Øzekad foHkkx@laLFkk@QeZ dk uke vkosfnr in
LFkku % xksj[kiqj gLrk{kj %
frfFk %------------------------------------ iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
ANNEXURE-08
eSa] v/kksgLrk{kjh] ------------------------------------------- iq=@iq+=h@iRuh@Jh --------------------------------------- ,rn~}kjk ?kks’k.kk djrk
@djrh gWw fd eSa vc iwokZapy cSad dh lsok esa ijhoh{k.k dky esa izfo’V gks jgk@jgh gW¡ w vkSj blh {kerk esa cSad
dh lsok djrk jg¡wxk@djrh jg¡wxh tc rd fd eq>s vkSipkfjd :i ls LFkk;h deZpkjh o` an esa u inLFkkfir dj
fn;k tk, vkSj ifjoh{kk/khu gksrs gq, esjh lsok,a] tks cSad dh lsok ds fu;eksa vkSj deZpkjh oan ds osru ds
vuqdwy] fdlh Hkh le;] fcuk dksbZ dkj.k crk,a lsok lekfIr dh frfFk rd dk osru Hkqxrku dj cSad dh
LosPNk ij rRdky lekIr dh tk ldrh gSA eSa ;g Hkh ?kks’k.kk djrk@djrh g¡w fd eSa veqDr fnokfy;k ugha g¡w u
gh fdlh Hkh le; vf/kfu.khZr fnokfy;k jgk g¡w@jgh gWw] u rks Hkqxrku fuyfEcr fd;k gS ;k vius _.knkrkvksa
ls lqyg fd;k gS ;k u gh fdlh vkijkf/kd U;k;ky; }kjk eq>s fdlh ,sls vijk/k gsrq nks’kh ik;k x;k gS] ftldk
lEcU/k uSfrd gkzl ls gksA
LFkku % xksj[kiqj ¼vkosnd dk gLrk{kj½
frfFk %------------------------------------ iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
ANNEXURE-09
vf/kokl (DOMICILE) lEcU/kh ?kks’k.kk
eSa] v/kksgLrk{kjh] iwokZapy cSad dh lsok esa ,rn~}kjk ?kks’k.kk djrk@djrh g¡w fd]
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
¼LFkku dk uke½
esjs vf/kokl dk LFkku gSA
*2& mijksDr LFkku esjk tUe LFkku gSA
;k
* mijksDr LFkku esjk tUe LFkku ugha gS ysfdu bls eSus vf/kokl dk LFkku fuEu dkj.kksa ls ?kksf’kr fd;k gS %&
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------
LFkku % xksj[kiqj
frfFk %------------------------------------ gLrk{kj %
iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
* tks ykxw u gks mls dkV nsaA
ANNEXURE-10
eSa ,rn~}kjk ?kksf’kr djrk g¡w@djrh g¡w fd iwokZapy cSad esa vf/kdkjh Ldsy& II in ij bl fu;qfDr ls iwoZ eSa fdlh
vU; laLFkk@lsok esa fu;qDr@dk;Zjr ugha Fkk@FkhA ;fn gk¡ rks fuEu fooj.k nsa &
laLFkk dk uke-------------------------------------
irk---------------------------------------------------------
in---------------------------------------------------------
dc ls dk;Zjr Fks --------------------------
LFkku % xksj[kiqj gLrk{kj %
frfFk %---------------------------------- iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II
ANNEXURE-11
iwokZapy cSad dh lsok esa vkus okys u;s deZpkfj;ksa ls izkIr dh tkus okyh
oSokfgd fLFkfr ,oa # ifjokj ds vkfJr lnL;ksa ds lEcU/k esa ?kks’k.kk
eSa] Jh@Jherh@dqekjh ------------------------------------------------- iq=@iq=h@iRuh Jh ------------------------------------- ?kks’k.kk djrk@djrh
gWw fd %&
* ¼1½ eSa vfookfgr@fo/kqj @fo/kok g¡wA
* ¼2½ eSa fookfgr g¡w vkSj esjh@esjs ,d gh thfor iRuh@ifr gSaA
* ¼3½ eSaus ,sls O;fDr ls fookg fd;k gS ;k fookg djus dh lafonk dh gS] ftldk ifr@ftldh iRuh
thfor gSA rRlEcU/kh NwV gsrq vkosnu i= layXu gSA
* ¼4½ eSaus vius iRuh ds thfor jgrs gh fdlh vU; L=h ls fookg fd;k gS A rRlEcU/kh NwV gsrq vkosnu
i= layXu gSA
* ¼5½ # ifjokj ds vkfJr lnL;ksa dk fooj.k ¼;fn gS rks½%
Ø-la- uke lEcU/k vk;q is”kk ekfld vk;
01
02
03
04
05
eSa lR;fu’BkiwoZd izfrKk djrk@djrh g¡w fd mijksDr lwpuk lR; gS vkSj eSa le>rk@le>rh g¡w fd ;fn ;g
?kks’k.kk esjh fu;qfDr ds i”pkr vlR; ikbZ tkrh gS rks eSa lsok ls inP;qr fd;k tk ldwWxk@ldawxhA
LFkku % xksj[kiqj gLrk{kj %
frfFk %------------------------------------ iwjk uke %------------------------------------
in % vf/kdkjh Ldsy& II * tks [k.M ykxw u gks mls dkV nsaA Definition of family : For the purpose of medical facilities and for the purpose of leave fare concession, the expression ‘family’ of an employee
shall mean:-
(a) the employee's spouse, wholly dependent unmarried children (including step children and legally adopted children),
wholly dependent physically and mentally challenged brother/sister with 40% or more disability, widowed
daughters and dependent divorced / separated daughters , sisters including unmarried / divorced / abandoned or
separated from husband / widowed sisters as also parents wholly dependent on the employee.
(b) The term wholly dependent family member shall mean such member of the family having a monthly income not
exceeding Rs. 10,000/- p.m. If the income of one of the parents exceeds Rs. 10,000/- p.m. or the aggregate income
of both the parents exceeds Rs. 10,000/- p.m. both the parents shall not be considered as wholly dependent on the
officer employee.
(c) A married female employee may include her natural parents or parents-in-law under the definition of family, but not
both, provided that the parents/parents- in- law are wholly dependent on her.
Note:- For the purpose of medical expenses reimbursement scheme, for all employees , any two of the dependent
parents/parents- in- law shall be covered.
**********
ANNEXURE-12
lsok esa]
v/;{k]
iwokZapy cSad]
iz/kku dk;kZy;]rkjke.My]
xksj[kiqj
egksn;]
funsZ”kh ukekadu
eSa iwokZapy cSad esa vf/kdkjh Ldsy& II in ij viuh fu;qfDr ds lEcU/k esa fuEufyf[kr nks O;fDr;ksa dks ftudk
uke o irk fuEukafdr gS] funsZ”kh(Referee) fu;qDr djrk@djrh g¡w] ftuls foxr o’kksZ ds esjs vkpj.k o pfj=
dh tkudkjh izkIr dh tk ldrh gSA ;s nksuksa@buesa ls ,d jktif=r vf/kdkjh gSa] ijUrq nksuksa esjs lEcU/kh ugha
gSaA
¼1½ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------eksckbZy ua0-----------------------
¼2½--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------eksckbZy ua0------------------------
esjs vf/kokl dk LFkku@LFkk;h irk fuEuor~ gS %&
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------
LFkku % xksj[kiqj
fnukad % ------------------------ Hkonh;]
gLrk{kj %
uke % ----------------------------------------------
in % vf/kdkjh Ldsy& II
ANNEXURE - 13
LETTER OF CONSENT AND AUTHORITY Date...................... Chairman/ General Manager(Admin) PURVANCHAL BANK ------------------------------- Head Office , Taramandal, Gorakhpur. Dear Sir,
RE: 1) Purvanchal Bank Employees D. Help Scheme
Policy No. :200551786 Premimum Amt.- Rs. 737.50
2) Purvanchal Bank Employees TIP Scheme Policy No. : 72100056308 Premimum Amt. – Rs 63.72 I wish to join the above Insurance schemes and request you to admit me as member of the Schemes with effect from the proposed Date of Commencement viz...............................I hereby authorize you to deduct appropriate amount of premium under the schemes from my salary starting from the salary of the month prior to the proposed month of commencement. I further agree that this letter of authority shall not be revoked by me so long as I am an employee of Purvanchal Bank. I hereby declare that I am currently in good health and not suffering from any of the critical illnesses like Cancer, AIDS, condition requiring open chest surgery, History of typical chest pain, Kidney failure, Brain Stroke, Paralysis or have undergone major organ transplantation such as Lung, Liver, Heart or Kidney. If for any reason, whatsoever, deduction of premium from salary is not made in future, I undertake to deposit the same at cash counter of Purvanchal Bank before the first day of the following month. I am aware that if the premium is in default for over 3 months, my cover will cease and that I shall not be allowed to join the scheme again. I hereby nominate Shri/Smt Relationship ...................as the nominee to receive the monies in the event of a claim arising under the schemes.
Yours faithfully,
(Signature) Name of the Employee : __________________________________ (in Block Letters) PF No : ______________ Designation : _____________________________________
Annexure-14
Payment of Gratuity (Central) Rules
FORM 'F' See sub-rule (1) of Rule 6
Nomination
To,
The Chairman/General Manager
Purvanchal Bank
Taramandal,Gorakhpur
I, Shri/Shrimati/Kumari
(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable
after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having
become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the
name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h) of
Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.
4 (a) My father/mother/parents is/are not dependent on me.
(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to the controlling
authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)
Name in full with full
address of nominee(s)
Relationship with
the employee
Age of
nominee
Proportion by which
the gratuity will be
shared
(1) (2) (3) (4)
1.
2.
3.
So
on.
P.T.O.
Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
8. Permanent address:
Village Thana Sub-division
Post Office District State
Place:
Signature/Thumb-impression of the Employee
Date:
Declaration by Witnesses
Nomination signed/thumb-impressed before me
Name in full and full address of witnesses. Signature of Witnesses.
1. 1.
2. 2.
Place:
Date:
Certificate by the Employer
Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised Designation
Date:
Name and address of the establishment or
rubber stamp thereof.
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.
Date: Signature of the Employee
Note.—Strike out the words/paragraphs not applicable.
Annexure-14
Payment of Gratuity (Central) Rules
FORM 'F' See sub-rule (1) of Rule 6
Nomination
To,
The Chairman/General Manager
Purvanchal Bank
Taramandal,Gorakhpur
I, Shri/Shrimati/Kumari
(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable
after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having
become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the
name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h) of
Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.
5 (a) My father/mother/parents is/are not dependent on me.
(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to the controlling
authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)
Name in full with full
address of nominee(s)
Relationship with
the employee
Age of
nominee
Proportion by which
the gratuity will be
shared
(1) (2) (3) (4)
1.
2.
3.
So
on.
P.T.O.
Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
9. Permanent address:
Village Thana Sub-division
Post Office District State
Place:
Signature/Thumb-impression of the Employee
Date:
Declaration by Witnesses
Nomination signed/thumb-impressed before me
Name in full and full address of witnesses. Signature of Witnesses.
1. 1.
2. 2.
Place:
Date:
Certificate by the Employer
Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised Designation
Date:
Name and address of the establishment or
rubber stamp thereof.
Acknowledgement by the Employee
Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.
Date: Signature of the Employee
Note.—Strike out the words/paragraphs not applicable.
ANNEXURE-16
EMPLOYEE DETAIL
S.NO
FIELD NAME DISCRPTION
1 P.F.NO.
2 EMP. NAME
3 D.O.B.
4 AGE(IF DOB NOT CLEAR)
5 MARITAL STATUS
6 FATHER'S NAME
PARMANENT ADDRESS
7 H.NO.
8 MOHALLA
9 CITY
10 DISTT.
11 STATE
12 PIN
CORRESPONDANCE ADDRESS
13 H.NO.
14 MOHALLA
15 CITY
16 DISTT.
17 STATE
18 PIN
19 RELIGION
20 MOBILE NO.
21 E-MAIL ID
22 BANK A/C NO
23 BANK NAME
24 BRANCH NAME WITH CODE
25 PHYSICALLY HANDICAPPED
26 P.H. CERTIFICATE NO. AND DATE
27 PAN CARD NO.
28 ADHAR NO
SIGNATURE OF EMPLOYEE
SIGNATURE OF EMPLOYEE
Family Details:
Emp. Name P.FNo
Family members name
D.O.B. Age as on 01.08.2018( If DOB is not clear)
Relation with employee
Disabled( Y or N)
Address with Phone No.
PROVIDENT FUND AND PENSION NOMINATION DETAILS
Emp. Name P.F. No.
P.F./PENSION Nominee name Share % D.O.B. Age as on 01.08.2018( If DOB is not clear)
Relation with employee
Address with Phone No.
P.F.
Pension
ANNEXURE-17
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ANNEXURE-21
PURVANCHAL BANK
PERSONAL STATEMENT OF THE CANDIDATE
To be filled in by the Candidate before presenting the form to the Medical Officer .
1. Name in full : .................................................................
2. Category of Post : .................................................................
3. Address : .................................................................
4. Date of Birth : .................................................................
5. Married/single : .................................................................
6. Personal History : .................................................................
A. History of Bleeding from Gastro-Intestinal Tract, Gastric of Duodenal Ulcer Appendicitis, Internal Piles, Fistula, Typhoid, Jaundice etc. Give details.
...............................................................................................
...............................................................................................
...............................................................................................
B. History of Asthma, Tuberculosis, Spitting of blood, Pleuresy Breathlessness. etc. Give
details.
...............................................................................................
...............................................................................................
...............................................................................................
C. History of Palpitation, Fainting Spells. Pain in the chest, Breathlessness on Exertion,
Cyanosis, Rheumatic fever with joint pains, Swelling of legs/face etc. Give details:-
...............................................................................................
...............................................................................................
D. History of Bleeding Urinary Tract, Painful urination, passing of stones or gravel in Urine
etc Give details :-
...............................................................................................
...............................................................................................
Contd......2
-2-
E. History of fits, Paralysis, Neuters hernia/Nervous Breakdown etc. Details to be given
................................................................................................
................................................................................................
................................................................................................
F. History of Leprosy, extensive generalized allergic dermatitis, Lecoderma, Venereal
Disease etc. Give details :- ................................................................................................
................................................................................................
................................................................................................
G. Have you suffered from defects in hearing or eyesight? Give details:- ................................................................................................
................................................................................................
................................................................................................
H. Details of serious illness injuries sustained by accident or otherwise. Give details. ................................................................................................
................................................................................................
................................................................................................
I. Details of surgical operations undergone :- ................................................................................................
................................................................................................
J. Is there any other item in your medical history, which you have not already mentioned ?
................................................................................................
................................................................................................
K. Have you ever been tested for HIV ? If so, what was the report ?
................................................................................................
................................................................................................
................................................................................................
Contd.....3
3
7. Family History:-
i) Heart disease & hypertension:
ii) Tuberculosis : iii) Kidney disease :
iv) Cancer : v) Any other serious ailments :
8. For Female Candidates only
i) Menstrual History : Regular/Blood History
ii) Date of L.M.P. :
iii) Any evidence of pregnancy :
iv) History of disease of Uterus
Cervix, Ovaries of Breasts :
Signature of the Candidate
Place......................
Date.......................
SIGNED IN MY PRESENCE
Signature of the Medical Examiner
NOTE:-
The Candidate may please note that he would have no right to appeal against the decision
of the Medical Examiner. If however, the Bank is satisfied on the basis of the evidence produced
before it, of the possibility of an error of judgement in the decision of the Medical Examiner it is
open to the Bank. Such evidence should, however, be submitted by the candidate within one
month of the date of communication in which the decision of the Medical Examiner is advised to
him/her. If the setting up of the Medical Board is decided by the Bank, the candidate will be
called upon to deposit prescribed fee for the purpose. If found medically fit by the Board this
deposit would be refunded to the candidate it will otherwise be forfeited. The report of the
Medical Board is final and will not be subjected to review by the any other specialist panel or
Board.
Report of the Medical Examiner
PHOTO
Name of the candidate_______________________________ Category of the post_________________________________
1. General development Good________ Fair________ Poor________ Nutrition __________ Thin______________ Average _________ Obese___
Best weight __________________________ when ___________________ Any recent change in weight______________________________________
Temperature______________________________ Height ______________ Identification Mark _____________________________________________
Girth of chest :-
(i) After full inspiration
(ii) After full expiration
2. SKIN Any obvious disease
3. EYES:
(a) Whether the vision is normal : Yes/No
If not is it capable of being Correct to 6/6 with glasses : Yes/No
(not with contact lenses) (b) If the candidate was referred:
To an eye surgeon’s
Observation in respect of
the following :-
1. Any disease
2. Night blindness
3. Defect in colour vision
4. Field vision
5. Visual acuity
6. Fundus examination
Acuity of Vision Naked eyes with glasses Strength of glass
Spn. Qyl. Axis
Distant Vision
R.E. L.E.
Near Vision
R.E. L.E.
Hypermetropia (Manifest) R.E.
L.E.
contd.....2
-2-
4. Hearing of : Right Ear _____________________
5. ______________________________
Left Ear __________________________________
6. GLANDS ______________________ Typroid ____________
7. CONDITIONS OF TEETH ___________________
8. RESPIRATORY SYSTEM
Does physical examination reveal anything abnormal in the respiratory
organs ? If yes, explain fully
__________________________________________________________
__________________________________________________________
__________________________________________________________
9. CIRCULATORY SYSTEM:
(a) Heart: Any organic lesions ?
Pulse rate
(b) Blood pressure:
Systolic
Diastolic
10. ABDOMEN: Girth_________ Tenderness ________________
_______________________ Hernia ____________________
_________________________________________________
(a) Palpable : Liver_________________Spleen_______________
Kidneys Tumors
(b) Hemorrhoids Fistula
11. NERVOUS SYSTEM: Indication of nervous or mental disabilities.
_______________________________________________________
contd.......3
-3-
12. LOCO-MOTOR SYSTEM : Any abnormality:
Varicocele etc.
13. Urinary Analysis
a) Physical appearance b) Sp. Gr.
c) Albumin d) Sugar
e) Casts f) Cells
14. REPORT OF X-RAY EXAMINATION OF CHEST:
.........................................................................................................
.........................................................................................................
.........................................................................................................
15. Repost of the Blood Examination : (including HIV Testing)
i) Blood C.B.C.
ii) E.S.R.
iii) Blood Sugar Fasting
PP
iv) Serum Cholesterol
v) Blood Urea/NPM
vi) Serum Cretonne
vii) HIV Test
viii) Urine and Stool
ix) Blood Group
x) Others.
contd.....4
4
16. Is there anything in the health of the
candidate likely to render him/her
unfit for the efficient discharge of his/
her duties in the service for which
17. The Medical Examiner should record
the findings under one of the
following categories :-
i) Fit ii) Unfit on account
NOTE: In the case of a female candidate,
if it is found that she is pregnant, she
should be declared temporarily unfit.
Place_______________ Signature of the
Date___________
Medical Examiner
Name:
Designation:
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