Computerisation of Personnel Information System (CPIS)

for Government of Manipur

Passport Size
Photograph
dully
authenticated
by Nodal
Officer

Form No: CPIS 4A

(Left Out Employees)
(Revised w.e.f. 01-08-2010)

Sl. No
1
2
3
4
5
6
7
8

Particulars
Name (in Block Letters)
Gender
Fathers Name
Date of Birth (DD/MM/YYYY)
Department
Designation
Date of Joining (DD/MM/YYYY)
Date of Joining at the Present Post

To be filled in

(DD/MM/YYYY)

9
10
11
12
13
14
15
16
17
18
19

Pay Scale
Basic Pay
Special pay (if any)
Place of Posting (Office)
District Name (Office Location)
DDO Code (7 digit Code)
Head of Account (15 digit Code)
Post Type(Temporary/Permanent)
Appointment order No.
Appointment order date. (DD/MM/YYYY)
Reason for left out
Note 1: All fields are mandatory
Note 2: Use A4 size JK bond paper
Note 3: Fields are to be computer typed neatly
Note 4: Documents relating to Clearance of the case should be attached duly authenticated
Note 5: Passport size Photograph dully authenticated by Nodal Officer

Signature
Name of the Authorised Signatory:
(in Block letters)
Designation:
EIN:
Date:
Seal
To,
The Special Officer
Directorate of MIS
Room No. 307, 308, 309
3rd floor, North Block, New Secretariat
Imphal 795001

EIN:
(to be given by MIS)