Application form for compassionate appointment under Notification SRO 43 of 1994 dated.22-2-1994 (dependents of deceased killed in militancy related actions).


1. Name of the applicant with full particulars 
(Parentage and residential address etc.)

2. Relationship with the deceased.

3. Name with full particulars (Parentage, Residential address,
Etc. of the deceased person).

4. In case deceased was a Govt. employee full details with
Office where working Designation, grade etc. indicating
Clearly whether the deceased was working on regular 
basis or otherwise on ad-hoc basis.

5. Incident in which the deceased expired with date specifying 
clearly whether the incumbent was killed: -

i. In cross firing ; or
ii. Firing by Security Forces; or
iii. In any other militancy related action.

6. Proof of non-involvement in militancy related activities both
in respect of the deceased and the applicant ( enclose 
certificate issued by an officer of Police Department). Not
below the rank of S.P. of the concerned District.

7. Educational qualification and experience of the applicant 
(enclose attested copies of the certificates).

8. Date of Birth of the applicant.
( enclose Date of Birth Certificate).

9. monthly income of family of the applicant from all sources 
( not applicable in case the applicant was dependent on the
 deceased employee) (enclose a certificate issued by a Revenue 
Officer not below the rank of Assistant Commissioner).

10. Name, age, occupation and monthly income of each of the
family of the deceased stating relationship with the deceased.

S.No.	Name		Relationship with deceased 	age	Occupation	income
_____ ____________ ______________________ _____ ___________ ________
   1           2                        		3		  4                 5               6

11. The undertaking duly registered on non-judicial stamped paper by other dependent/eligible family members to the effect that they forego their claim in favour of the  appointee.

12. Certificate from Revenue Officer not below the rank of Assistant Commissioner to the effect that the applicant was wholly dependent on the deceased.














13. Undertaking from the applicant that he/she will serve the family members of the deceased with the income derived by way of such employment.



Signature of the applicant





	( For use in the office of Deputy Commissioner Concerned )


1. Certified that the above entries from S.Nos. 1 to 13 have been verified and found correct.

____________ ________________________ _________________________

__________________ ______________________ _____________________

2. Whether ex-gratia relief has been sanctioned and paid to the NOK of the deceased.

3.	Whether a suitable post has been identified/reserved for the applicant's appointment
( give details showing designation, grade and department) .

4.	Recommendations of the Deputy Commissioner ______________.




							Signature of the 
							Deputy Commissioner