APPLICATION FOR DECLARATION OF PROBATION

1

Department Details

Name of the Department

Name of Head of Department

2

1.(a) Name in Full (CAPITAL LETTERS) - Leave blank for handwriting

SURNAME

NAME

Aliases if any / Added/Dropped part

* Photo Box will be shown in PDF for manual pasting - no upload needed

3

1.(b) Designation & Working Place

(i) Designation

(ii) Place of Working (School/Office)

Working Mandal

Working District

(iii) Date of Entry / Appointment

(iv) Category

4

2. Address Details - Present & Permanent

a. Present Address

House No.

Apartment Name

Lane

Street & Road

Village

Mandal / Taluk

Town / City

District

State

Pincode

b. Permanent Address

House No.

Apartment Name

Lane

Street & Road

Village

Mandal / Taluk

Town / City

District

State

Pincode

Mobile Number

Landline Office

Landline Residence

(c) If originally resident of Pakistan - address & migration date

5

3. Places Resided in Preceding 5 Years

#	From (Month/Year)	To	Residential Address Full	Police Station & District
1
2
3
4
5

6

4. Father's Details

a) Name in full with aliases

b) Profession

c) If in service - Designation & Official address

d) Present Postal Address (If dead last address)

e) Permanent House Address

7

5 to 8. Nationality, DOB, Place, Religion, Caste

5(i) a) Father Nationality

b) Mother Nationality

c) Wife/Husband Nationality

5(ii) Place of Birth of Wife/Husband

6.a) Date of Birth of Applicant

b) Present Age

c) Age at SSC/Matriculation

7.a) Place of Birth District & State

b) District & State to which you belong

8.a) Religion

8.b) SC/ST/BC/OC & Grade A,B,C,D,E

8

9. Educational Qualifications Since 15th Year

Course	School/College full address	Date Entering	Date Leaving	Exam Passed	Police Station & District
1.SSC/ Matriculation
2.Intermediate
3) D.Ed / TTC
4) Graduation
5) B.Ed / B.P.Ed / Special B.Ed
6) Post Graduation
7) M.Ed
8) Any Other Qualification

9

10. Employment Details

Designation / Work	From	To	Office Address Full	Dismissed/Removed/Resigned Details

10

11,12,13 - Legal & Referees

11. Have you ever been arrested, convicted, detained? If Yes details (If No write NO or leave blank)

12. Referee-1 (Not blood relative)

Referee-2

13. Member/worker of Political Party / Communal org / Youth / Student / Service / Labour?

Declaration - Marital Status

Declaration Place

Declaration Date

11

Extra Ordinary Leave & No Allegation Certificates (All Optional - Leave Blank for Manual)

Extra Ordinary Leave Certificate

Name of Teacher

Designation

School

Working Mandal

Working District

Status

From Date

To Date

No. of Days

Station

Certificate Date

No Allegation Certificate

Name

Designation

School

Mandal

District (Leave Blank)

Station

Date

APPLICATION FOR DECLARATION OF PROBATION

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Extra Ordinary Leave Certificate

No Allegation Certificate