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A PPLICATIO N FO R ISSUE O F NO O BJEC TIO N C ERTIFICATE

FO R O BTA INING INDIA N PA SSPO RT

Nam e ofapplicant

Designati
onwith nam e ofOffice

3. Perm anentaddress

4. Payandscaleofpay

(a) DateofBirth

5. Date ofcommencementofcontinuous
service underGovernment

Place proposed to be visi


t

Purpose ofvisit

8. I
fitjsforseeking employment,whether
a decl
aration to the effectthathe will
eitherresignthisjoborwilltake prior
permission abroad has been attached

9. Exped ed peri
od ofabsence from duty

10. Address ofthe place ofvisitifavailable

11. How theexpenditureforjotlrneyandstayabroad :

12. Mode ofdisbursementofIeave salary

13. W hetherany disciplinarycase is


pending againstthe applicant

14. W hetheranyIiability is outstanding


againstthe applicant

15. W hetherapplicantis underany


contractualobligation bonded ornon
bohded with Governm entis so detai
led

lSolemnlyaffirm thatthe information given are correct

Signature ofthe appli


cant

1,.............-....-.......................................-...................................01fprfpt)jt(1(,1)11,rtrthll,t1hslI
-ll()lltll-
lrlr)rit)rr)llrryl-
lislp-
l()r1frl)rrltkl(,
Governmentbefore I eaving India to abroad. .

Signature ofthe applicant.


PR O FO R M A REPO RT
(Tobefilled fn by theHeadofOff/ce)

W hetherany discipl
inal proceedings
are pending orcontemplated against
in indi
vidual

2. W hetherany Vigilance case is pending


orcontem pl
ated against him

3. W hetherthere are groundsto believe


thattheapplicantcouldfigure adversely
onthe securi
tyrecordsoftheGovt.

Certi
fiedthattheinformationgivenaboveandthatgiven bytheapplicantSl.No.1to 15areverisedandfoundcorrect.
His application is recommended.

Signature:

Name:

Designation ofthe Officer:

Station:

Date:

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