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D. G. P. Secre tarY,
12. P ri ncip af,
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Pol-ice
fl.Lar ei- riE
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( i.llot
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Add]. D. G. P. lJ. u. P.
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15. s.p. c. B.
il

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Secur i Lv. I n'iei.! i ge rlce. f ngel-Iige;Ice'"

l.J,ii. & R ange


I'l , i,riul. 5. -r .
qof legtor. D .r . G . ( P ) .
AssL' 5' P' of
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ri D D. l. G. lj,. !it'ec LJr- CIIILI-


r.-, . Ad.tI. s. P .
Ltt Lel-l lrjence. Addl. D. G. P,
C. B. /' S. lJ.
r ntel {.i,lejlc.j.

ir. o. P.
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( Vr g -r-.,-.+rce ) .
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Dr-re c tor cilr ef se.ie Lar)'/


20. A" r. G. secre tari
(vigiiatrce). ( Vi 9:- allce ) / (Vi;1i1aiice) .
j.
Vlgi] a;rcc.
( lti} airce) .

'2:. Grvei!rJr
, Ai cl- de- cainP
Lo Governor. of orrssa.

'22. r.G.P./ Addr' D' G'P'


r-::ir,taaAd <rilt, ( s. 4.9. ).
u5ilP (rjac. j. (s.aP). Special
T r: i-)

( s . A . P .) .
IY ansporL Secretary, C. S. or V' S' o'
23. . Tra')sport j-rr-char!e of
(.lJ,lxni sj s - Tr ansport-
fr'rr:rr. tlte ll]::,.)Lt.
( Eiljjar. ceriie '1t ) ' Io r'Ier'
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c r a t - + 1 . - : - - jlcu.,rL:li-r '.+
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( z) (3)
( r)

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2. r{e9i.,L.raI. 1
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(b) Establish I
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? pol-ice r/eif e l-: cL-.
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( ii ) Districl- Po.Lrce'
i. P . D. I'1. Ranqe
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5. P.
D. i'{ . D:Ltto.
S. P.
5. D 5. P.
Special I. G.
D, I. G.
5. ii, s,P. cf P o l i c e .
( C.ri;tie Cr rtrie
br- aYi ci'r ) .

I. G.. ot
l nLef ii.- Poirue,
1 :ipeci al.L ile IIce, IllteL I r ge'lc(r/
l.jr ailcn ) . 'Lioilar
Addi
t G. P.

. . . D i. (,. +.dii ti-',ial


r l i D
LJ.
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( RdLi-wiryt ) . R.[!wiiys'
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p-ciilcipaI. Spe_cla.i DG. & I. G.
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11. Prrl.Icipal, r. c.(P).
r'. i. D.

.1 -:..r' ,r_i I r bec.re t..fy, spe aj<-e!


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(r) ( 4) (6)
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l. iJ. P. u. /' s.P. (uist. ). r r .] . . G . ( P )


13 . I t I S r ) € r ca D . r o r
I-.(ang€..
Porj-ce, Ci jicie. D. $.P. / .
:rdcl-L Li i i'tal-

r.s.P./ b,.,P.(uisL. ). uitto.


t4. I . - 1. C .

$, D;P;O./ 5;P. ( Dist. ). D.I. G. (P)


i5. I ilspec Lrr.,
D. S. P. Raflg-e.
v$.)Itieil.

ire pu ty Ocr,Liiia,ird ant. I. G. ( ir ) ,


1;. s:f {a{ S. AP.
llcil r. Qtrru'r arrd an t. ,
-uioirai ir. I. G. ( P)
17. I il:lnector, D. b. P. Add:.
i). 1J. i-. . i r D / Ran.lie.
Lair-
{rddi ti o ,l ar sb P. Dist.
s ; D .P . o .
teiru L:, q)lnrrr.Lild arr t. I. G. ( P )
lE. Subecier.
Cl"I,'l and aill-. S.:i.P.

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1.9.. IiliEtfrrid..igitd
J(Ejj.ij!{ESt . ftlGjrftrs4c*. (Raili$rylt*. kit^aid.raasx)"
(rOix.til'
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af,-?irciE).

19 " Ins.lec c.;r D. -r. G. (P). r . ( , .( P )


( Cr iL,ic sec Li o rI it airg'-. C-rrl{re.
Raige) '
j. p. I. G. (P)
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( it .ri I vraYs ) . ( Raj] wal s ) ,
i.( .ri.L '.t a)' sj ( Ruli *ar,) .
( L r .I . G .
i( +,I I r,vc1-t s
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Vige.- , G ) l u na n c i a n i / l. G' (P),
2 l. I jlslJ€c LJ!,
S. L Y.
iirLile -l Pcl-..1-c€ P r.! jlclv ai . lrg flclp i1i.
]tdl-.ri 'r!
Ceatr e.

U. p. P. s. F. (Dist; ). ,. I. G. (P) .
22. j(eserve
Iil:jPe c t.)r. . Adda $ci,lai
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5. -o. ( C, iB. ). D.r. c. (P) l. G.(P), (c. B. )/


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( c- rr. ) . Addi. D. G.
D, J. r':.
s:.tuar: C.
r\ q .J / s. P. D.r. G.(P),
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( VtqiL alrce ) . Ador ti o;tai ( Vrgri a,:ce ) . vj-gil ance'

t l r L rt - d - - P . . 5 / -
ii J /
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,- 'JI' ,ilec Lrr, P. P.
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Pol ice ( Sl" ) , (j. d. ) I r1-erl-i!ence.

27. I nsrlec !..ir ,Jr: s.P.(c.B,). qr.G. (P) ( C.B.).


Poiic; ( eE) . (c.'.)
28. Ii,xspe c Lr;" Xji!{ D, i. P. D. I. G.
11. rli l1. \-. (ri.rr.P.C.).

29. Irrs,:octoji, P ri :rcip ai . 1 . .G . P .


P; T. C. It ei ni iig,i
n d d i . . D ,G . ( P )

30. I nJpec tor, titi:o, Dr'.G,(r'),


']Y
E. L. v. ai Ili rlg.

3 1. f nsilec l-o j: . r . ) i P , . r . G .( P ) ,
T. R. D. 1]r di aing.

3 2. 1 fls pec l-J-i:, u. S. P. iji tto . r. G,(P) "


s. p. .i. training/
,dci. il. G. (P).

3 3. I nspec tor, Pa-riliip at. D. 1. \,. ( P),


T, ir'. b. lr at iu ;i9.
(brnxir -i.ird aji-rt.

f 4. I i.r3ricc t,Jt, D. 'j. -". S. ir. DiieQ LD.L-, l'. i! S.


,,r,.,u
Ler.
foJr.:,i,,. l:ojiu.:t",.
35. I-rspeciJ.r:, , . , .I . G . ( P ) . u. r. G. (Pi. I. G. (P) .
S i:ate (birrro-L Adrlilu-s aLiJA.
Rooaii.

3d. I.rspec Lrr, --,r.t.(r).


Crorrt r -ieriti al
Po-i rce ii. u-rs,

3'1 . Iirspec Lui--, i D I. \J. ( I/l , .E. b. 5


!-inge r Prl ilt
Ilure iio-.

3E. frlsp-:cLui, ]J. ; P. I.G.(!)),


P ito LO ii. (Jrs, ( Jiio 1-o) Cr ]-ine (jri-rrre tsr.r.'ic
l - i . q IJ.r aicn. A.lCi . il. G. (P).
39. Lt€;ire c.Lore i r S L s ti'
114rrdwri tin-; ffitre Brarrcl)/
Rlr-re aLl . ;ddi . D . G. (p).
i/ 6
Pieoortii:j qlun Lex- ;Cce ji tr ir!'
SL ur:iicerrf
r\lo. re )oj: ]:eo L ie
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!+..e.-9.
;rLi Cilor i i:re s.

(r.) (2) (3) ( 4) (s)

lJ, I. rr. (Y r.
40. I ; \ i ' , ) t a a: ' L ,
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PIi) Lec Lii;r oi
Crvi r i"! liL c.

1 , .P . ( r i s L . ) , i. I.v. (i') . l.G.(P),


4I . i ilslr.- rj ,--,.,;-,
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i"leciralric cl-/ ( s:..j.'^ar ) . (siEnaf). Lfecir;rj-cel ).
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43. I : r s . L : at ' j ! , U. o. i" S.u. ( Dist. ). IJ. J. U. l|t'l

D. C. i1. g.
( R.ange) . .

rils!)ec.-r, t'r'i" (r)' u. I. G. (P)


44. ( ;rd,,ill. ).
Gri ev a:ice Cel I. ( Adii n. ).

+ rj. D:|r.ec ioi, F..9. S.


45. 1 nspec Lot,
F r o e r a t L ' i Lni 9 ( C o m p u ' c e r ) . ' ( oo,nputer) ,
Ckjirij )u --eI.

46 . Subed ar (I'r ' 1'. ) C. D.r.G.(P),


.D, conpu i:er.

4'7, I.rtsr.' c c:rr ot rr li D s.p. (s. B.). D.r.u.(P)"


r"
(s.i,.). ( s . B .) .
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;rer-o droiit'

of 5. P. ( Illst. ). D. I. G. ( P )
4t. I -t-,:,"cC;r
R ange.
I r c ) 1i c a , . r(l!,t-L . v. E .

BaI l-(nel a
Prcjeci:-

t i . 9. S. re:.tiji !u J ol il i:

o'i ! L... / lirec toi:/ Di rec k)r/


e.
Se liL'.if JlLt.-,(l. r.

' S: re,r LLr l-.i


Zts)JL.

J. 5. P. ( S' ir' ) . r j .P . ( s . B . ) . r+ I. G. (r)


50. I.!r!p€c .J-t o:.
i -iILel- -Lr gelrce.
i?orl..jt: , V, I. .P.
SeJLii i tl'.

Vice - PrIrjcl-PaJ. u. f. G.(P),


51. I r r s r )= c L o r c ! '1Yai' iti jtj.
Poii.e, l ' . T . P - S. P l: r -rCI !t ar-L.

v. p. v. / D. I. G. (rr).
52. r.ts,,.,ccu.-,r,
'
{}li:l-
, , i r'1,:

oii P r r 4rcr? al- Dp,L. I. \'. \r',/


::l3. lit-spccaJ-r
,9nl-iec, tl ai ni it..t
( D.ril} ) . Cr-ordinatj-on
& Direc LDr'
rrciji: , Li;i:l f<eriiaLrli,-i -

-"i";
(j,

c. ( iecir. ).
P c j -- r i e (Pl:je,-.r). ( sr'j,r...r).

56. Assi-. iJ alt


D. ( c. r',.)
( CI'j-LfLe
:r erncii,i .

57. f ; r s i r ec ' . o - L ' o f D. I. G, SpL. I . G.


P()iice ( i - , ,i ' i . t . 1 . ( t . i ' r . I ) . 'I-'si&
r .i

58. i I r : i r) c c t i f c f D .I . G . spl.l-.t. (F) .,;


P c i . r - c c ( , - : r m e r ; , ( adian. ). AiL,rn.
( i i ) S , . ' e c r a i a r r i r eJ P o l r c e .
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ij C. llr+'..loft{..aria.1'i'ts,/ (i)irli-n air.- u. I. G. ( I ) . iipeci al_
darrr,-. ^ I. G. ( P) ,
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. r rrre rIJ <u r !. r.G. (P) i. L;. (r'C,IICe),


(l)lllIlt ti].it-i ir-r: e (P.i',.c.). tr ait}l n9/
S{.,. j i ,l I rr.r ,.i L .ary iI dj-r'!i,:! Adcil . D. G.
(Poirae).

( iv) ioirce Ra.iio .ii- i <-r.

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o i P o l r -c e ,
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ltre IJepu ty CoLamissj.olrer of L-oIice,


5 .1"-y.-L-e -il .e.-9....r.r,i-l:
Bef:- Your l-etter .b.400/corL dt. 15.2.2008.

,sJbl- R€garding o.:nlnunic atio n of adverse


qC- R. remarks to S. rs of, PoLice.

As per the provision laid down in .Par a. 14. (IV) of


G.A(s.E") Deptt M e m o l \ l c . 7 4 8 0( 1 2 0 ) , / s E dL31. 10.90.
' n Ren arj(s of, Lfle oountersigning offlcer shalL
prevail. gv€r tfrat of, the reporting officer. Sjmil Erty,
remarks,of the Acc ep ting Artiority sha].I prevail over
tho se of, the CountersiEning Off .icer. Mverse rema.rks sha"ll
not be coftnunlcated iJ remarks 1lke rrA'pod off icer'r,
{a very goo d off icerr tr dr e:{cellent officeiu or an.'
outstandlng off icer have'been iecorded .by :d -hlgher
officer. Gener al remarks J-rKe
ike n
" r,o
eorli satisf etoryu and
I average off icerrr a !€u.Ld rI)
r t co.u nter b.al aflc e adveise
rgnarkstr.

recorded at aJry level- of assessmenL with


wi1 the overalf

oriss+ ol t.tack.
Iierlb -*'li **--J.ecR-celJ-. Dated. 26 . 2. 2008.
Copy fgri,,rarde,l to A+I Heads of Police, Eshts., OrissE
f,or inforrnation and 9J idarce.
t
\.
\
:
I- c. of Policd
or j-ss an or ttac k.
Gove!'nfitent of Orissa,
G e n e r a l A . d m i n i st r a t r o n ( S E D e p a r t n r e
) nt.
r*. ftl93,sE Datec '
Frorn ?J 1 .?Mx
Lerr;a.jAS (.SAGt
Srt l.,1
AddiitcrnaI Secretal- tc Go',,efnrnent

To

All Prlnctpal
SecretarrestCom
m isstoner_cu
m-
Secretanes.,
Secreraries/Special
Secretaries/A!l
Heaos of Departmeni.iAli
R.D.CsrallColiectors.
Sub: A m e n d m e n It n S c h e d u l eo f I n s t r u c t t o n sf o r
r e c o r d i n go f
in theperfcrmance
Rerna:'ks Apprais"fn"pcrifinhl
PoliceiOther Officialsworking'in tt e Cornmisslon"r","
"f
Sir,

I am o,rectedto say that after careful constderation


Governmenthave
been preaseoto Incorporate the fo|owing reversof AssessmentIn the schedure
of Instructtons issued vide this Department lener
No.1Og14/SE dated
26 12 2003' as new rtem '(h) porrcecommrssronerate'
underthe heading (13)
Home oepartmentfor recororngof remarksrn the performance
AppraisarReport
(PAR)of Polrcei otnerOtfictaisworKingrn the Commrsstotnerate.

OfficerReporled upon Repor-ting -


Author.i|l Revielvrng AcceptingAuthori
4g!!sril
P, ChiefSeiietiry-e hrefN4n,ster

ChiefSecretary
na:D

D , GP .
a
_l
. a ' , , - r , - i : in . 1 . 1 . I a.i-inilnd;.r
":ll' C D a i:)
/ nl.t
r-ap
7 AddD
I CP
3 ACP
iHGsr a\aD
9 ACP
u L , r J F l j r
-Tl
i ' 1A s s t C o m m d t
Commdt A d d tc . P
CommdtTthBn
'13 ln-spegtogTTl D S P / A s s t C o m m d tP. r i n c i
14ITC D.C.P, cP.
n,J i-^ ^. ^, t^a^ll;-^F
L./!,l,tc' .Ll , [v rg('r rl
l.J,ll lJlrveLvl, !-/ I u
trtrr Cnmmclt L;OmnlOt. 1,.r.
16 SuDedar -A.C.P.
17.lnspector, Ciime Crime A d d l .C . P CP
Sectron.
1C q.;d^i;fi. nffi^a'
D.C.P. r Director.Health

2 2 C . l .o f P c l i c e .
23-inspector.-HRPC
-PCrP-,- C.P.
DCRB
24.lnspector, A C P:- jlqjL c.P.
n:{.9_o4Aq!-----*Py=Commcjt C.P.
-'--
i_5,Subeciqll\{,T1 l-)irantnr F P
2O..nsst Public ACdl.P.P./P P. D.C.P.
Prosecr.ttor
fTl
21 f.:afficEngineerot- PrinCipal,
TTI
28 Establishment D C P (Hqrs) Addt.c P CP
Officer

Thts may be brougntto the notce of all concerned under your


ccntrc!.
adrninistratlve

Yoursfarrnfully,

of Hon'bleChiefMinister,
kindinfornration

AdditionalSe
G c v e r n m e n to f O l s s a
G e n e r aI A d r n i n i s t r a t i o(nSE ) D e p a r t m e n r

No .>t __/Jte : ). :. z'. .q


, , * 4tu \
CS("' -
S h r i B . B . M o h a p a t r aI A
,S - l
AdditionalSecretaryto Government a.u
rt')
'u\\^u
To
f ..- c.I4t-,, . Q \
HomeDepartment
NLL
S u b A , r r r d i aS e r v i c e( p - e r { o r m a n cAep p r a i s a i
R e p o r t )R u l e s ,2 0 0 7 -A n n u a l
h e a t | hc h e c k -u p o f l . p . S .O f f i c e r s_ r e g .

A s p e r t h e A I S ( p A R )R u l e s 2 0 0 7 a n d a m e n d m e n i s
rradernereundei
annualhealth check up rs mandatoryfor ali lpS
officers The summaryoi the
rnedrcarreport irn part-c of Fcnn- rV) rs to be aftachedto the pAR by the
' memberof the service The pAR arongwith the summary
of the medrcarreport
shall ce kept in the PerfortrancsAppraisaldossier
of each nremberot the
Service
2- -The€ overrrmerrt*ra
vejiraiized the.gaekage :aie fu,rthsrnediear eheekup
@ Rs 1500/-per officerto be ccnductedin any of rhe fofiowrrrg Governrnenr
as
wellas PrivateMedicaiCoiieges& Hospitals.
oJg11U1eIrr M-qdlgal Co ||eo es,& Hos p ita I
_LjS!_gL_q
(r) S C B. MecjicalCollege& Hospital.Clrttack
(ir) l , l K . C . G .M e d r c aCl o i r e g e&, H o s p i t a iB e r h a m p u r
.
(iii) V . S . S .M e C r c aCl o i l e g e& H o s p i t a lB, u r l a S a m b a i o L r r .
1 r v ) C a p r t a l H o s p i t aBth. u b a n e s w a r
-l.:,ls!Sfpr'vate trtedicaIC
(i) K a l i n g aH o s p i t a E
t ,i hu b an e s w ar
(ij) K l l v l SM e d i c aCl o i l e g e& H c s p r r a B
l.hubanesrvar
(iii) hr- fech lvtedical Coliege& irospital,Bhubanes,,var
(tv) S U M M e d r c aCt o l i e g e& H o s p i t a lB, h r J b s 6 s s , ! v r r -
3 T h e H e a l t n& F a n l y w e l f a r eD e p a d n n e nhla v e a , s c S S - i c . i t € s S a . v
l n s t r u c t r ot o
n t h e a b o v er r e d i c aCl o l l e g e s& H o s p l t a /fso r t e a t h c r e c x . : o c i F S
officersrn theirretterNo 3637dt i6 2 2009
4 S i n c et h e H e a l t hC h e c ku p h a s b e e n m a d e m a n d a r o r yt h e a u l h o z e d
hospitalsshall performthe requrredtests and examinetionson productlonot
identityand proofof dateof birth.
5 The Govt as well as Prrvatehospitalsshallundertakethe healthc.heckup
as containedin Form-lV{copyenctosed)and submitthe reportto the Officerduty
srgnedby the Superintendent
/C.M.O.concernedon paymentof Rs. 1500/-oer
Officer
6. The expenditurefor conCuctinghealth check up wrll be borne by the
concernedDepartment
/Organisatron
etc. and reimbursed at par with the R C.M
claims in the establishment
in which the salary of the Officer(s)is drawn on
submissionof necessarydocuments.
7 This mav be brought to the notice cf all IPS Officers concerned
immediately
8. This has been cor,curredin by Health& FamilyWelfare Departmentjn
theirUOR No. 4326/5 H&FWdt. 27 12.20:08 andiry Financepepa rtmentin thef
UOR No. 1275tPSF dt.27 3.2009 i/
A . ^ L, 't l] ,-t"- , ,
AdditionalSecretaryio dovernment
'79
Memo No. 4 Dt 13.04.20@
Copy with copy ci enclosureforw,ardedto Sr. P S. to Chief Secretary,

I Orissa/D.C.-cum-A.C.S.,Orissa/ Member, Board of Reven.ue.Orissa/Chief


Administrator,K.B.K. for kind information of chief Sbcretary/D.C
A.C.S/t"4ember,
Boardof Revenue/C hrefAdministrator,
K.B.K
-cum-

Joint
l/)

t ' . ]' r = D - - ' " : 1 : = '"-" " -- ':


ts.jl'e l"/'a:l'c
: a c : v ' / v l i l 'c c p ! ' c r e n t
[ l € c € S S 3 isvc i i o l
i r n f o r m a t t c na n o
D e p a , t n r e nf o
I

?9b Dt 13'04' 20CE


MemoNo. \ /,///'
to the D C E t C of Polrce Crtssa
Copy with copy of enclosureforwarded
and nec€isary action'
for informatron
L
se}.etkA5
Loint erRmeru-
\ - l -- 1i ; ' - l
797 13.04.20@'
Menr':No.
(by name) for
forwardedto all IPS offrc':rb
CoPYwith coPYof enclosure
and necessaryaction
information
(

13.04. 20@
79a Date
Memo No.
f:Yfl*1 t-,*:i"t? lli"J'iltt"l'i,3'
ofeIcr:syre,
copywithcopv

dated162200e
P:f,iT:ili;'3:,#;ii;ffi-;''i'ro 36szrFrirv
joi nt S/cr"elary iGQPenm ent,t
;:' \'-.'
' \a' :l-\'l
?' -o-q \3'o4' 20@
' M e m oN o . Dt
c
the Health & Famrryvvcrrcrr
99 jv tvitn copy of enclosure-forwa'-d,"d^to^ nt i10 (ten)
/Finance
Department -p"liliiyi*" :::tr:ji:,"t
andnecessary l.lJJ'''"
action
i"i;t"rmation
r;r"
3;i,1lIiii.'l;gl.fi i .t

M e m oN o .
80o u4lc
*s::i#'ktvs|'n
r S . O a .z O 0 9

CoPY forwarded
necessaryaction
( )
.t,t dl--

'.,,
{
.'/

Annexurc

Fo'm lV
[ s e e r u l e3 ]

R e P o r t )R u i u s 2 0 C 7
T h e A I I l n C i a5 e r v i c e( P e r f o r m a n c eA p p r a l S a l

t t ' r c x u pr o n t ' s o r f l c t ^ s
p a o r o n v or o n x E a L t u

Sax: l t i , /F
AEE
NarnL_

Weight Chest E\pa|i:.,o.


He i g h t

B r i e f c l i n i c a lh i s l o r v , i f a n v :

I : E x am i n a t i o n

A . G c n e r aI P h Y s i c aEl x a m i n a i r o n

B S V sl , e m i cE x dm i n a t r o n

C. Hearing

D. Vrsicjr'

ll. lnvestisations

Hae!'r'oEram

Hb%

Tr_a

DLC

P e r i p h e r aSl m e a r

Blood Sugar

P.P

Lipid Prollle

Total Cholesterol
)- ,. _, ,,..11t,l

i-L !iri,la,!irrirt

r r! D / . C h o l c 5 i c r c l

i t L l f . . , t) o a

L i v e r F L r 6 s 1q 6 T s 5 1

T o t , r tD r i, - u b i n

i l r a €c t B r l r i ub i n

l r i . j ri i. (I B r l i ur b i n

SGOT

5GPT

/ \ L K P h o s p ha l a 5 e

5 P r o te i n

Alibumin

clobutin

K i d n e y Fu n c t i o n T e s t

Urea

Cr e at i n i ne

UricAcid

Electrolytes

li a+

C.a
lcium

InorganiP
c hosphates

CardiacProfile

CPK

CK-M8

LDH

SGOT
Urinc

Rouijnc l'/,tqascoptc

5ugar

Albumin

X - r a yC h e s t

U l t r e S o u n dA b d o m e n

Hearing

Vision

Physical EfticiencYTest

Any other Investltatlon

Advice

B: Medical ReEort of the Of{icel

,lormaULow
1. Haemoslobinlevelof tlE olffigg!
) Satisfactory/Normau Htgh/Low _
Ilood sugarlevel
Chol6terol level of the officer Normat/ High/Low
dVsfunctioning
Satisfactory/No|.mal,'
4. Liverfunctioning
Normat/Both-one kidneYnot f unctional
KidneyStatus
oPtimallY
e CardiacStatus lilormal/enlarged/blockd/not
UnderweiSht/Normal/Overwei
normal
ght/Obese
7. BMI
(BodYMass Index)
6- Test
Endurance -t€iiFr-tsFoffit4ow
C j S u m m a r y o l M e d i c e i R ( p o 1 1( . o p y t o b e e i i a . h e . ! o p A R l

g [ , ! e _ ,_ - _ _ _ , Exc<ljeni/Veryca.!,ic.oci!,.\.,,t:,:-

r n e d i c acl h e c ku p o f t h e o f f i c e r
W h e t h e rF i t f o r F i e l dD u

Oate S i g n a t i r ,f . o f t r i e C i c z A
l oiltcriiy
De5l3iletion

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