Government ANNEXURE – 1

Aided Ednl. Institution

APPLICATION FOR ADMISSION TO

THE TAMILNADU GOVERNMENT CONTRIBUTORY PENSION SCHEME
( G.O.Ms.No.430,Finance( Pension) Department , 06-06-2004)
( To be furnished in Duplicate)

S.No Details
CPS Particulars
Name of the Applicant Index Number S.VASUDEVAN
1
2 Sex Male

3 Marital Status Married

4 Official Designation Junior Draughting Officer
Office to which attached Office of the Divisional Engineer , Highways,
5 Costruction & Maintenance , Cuddalore.

6 Service to which the Applicant Belongs Tamilnadu Ministrial Service

7 Date of First entry into service 14.03.2013 F.N

Whether appointed in Govt. / Aided Educational Government

8 Institution
9 Scale of Pay 9300-34800-4200

10 Basic Pay 9300+4200

11 Date of Birth 27.12.1967

12 Date of Superannuation 31.12.2025

Whether appointment is regular or Rule 10(a)(i) of the Regular

13 General Rules for the state and Subordinate Service.

14 Whether recruited for Pensionable Service No

15 Community of the Applicant SC

16 Details of Nomination
(a) Name of the Nominee V.Bhuvaneswari
(b) Age 36
(c) Relationship Wife

17 C.P.S. Plan opted** Plan-1 / Plan-2 / Plan-3

18 Remarks, if any

Station:
Date : Signature of the Applicant
CERTICATE TO BE FURNISHED BY THE HEAD OF THE OFFICE
Certified that Thiru / Tmt / Selvi__________________________________ is a regular employee
appointed
Date : to Pensionable service and is eligible to join the Tamilnadu Government Contributory pension scheme

Divisional Engineer
Station : Highways , Construction & Maintenance
Cuddalore
 ANNEXURE – 1

APPLICATION FOR ADMISSION TO

THE TAMILNADU GOVERNMENT CONTRIBUTORY PENSION SCHEME
( G.O.Ms.No.430,Finance( Pension) Department , 06-06-2004)
( To be furnished in Duplicate)

Particulars
R.THENMOZHI
S.No Details Government Male Female
Aided Ednl. Institution
1 Name of the Applicant Married Unmarried
2 Sex Road Inspector

3 Marital Status Office of the Assistant Divisional Engineer ,

Highways, Costruction & Maintenance ,
4 Official Designation Tamilnadu
KurinjipadiMinistrial Service
Office to which attached 23.10.2013 F.N
5 CPS
Index Number

6 Service to which the Applicant Belongs Government

7 Date of First entry into service 5200-20200-2000

Whether appointed in Govt. / Aided Educational 5200+2000

8 Institution

9 Scale of Pay 15.07.1981

10 Basic Pay 31.07.2039

11 Date of Birth Regular

12 Date of Superannuation Yes No

Whether appointment is regular or Rule 10(a)(i) of the MBC
13 General Rules for the state and Subordinate Service.

14 Whether recruited for Pensionable Service

15 Community of the Applicant R.M.K.Venkatesan

16 Details of Nomination 43
(a) Name of the Nominee Husband
(b) Age Plan-1 / Plan-2 / Plan-3
(c) Relationship
17 C.P.S. Plan opted**

18 Remarks, if any

Station:
Date :
Signature
TO BE FURNISHED BY THE of THE
HEAD OF the Applicant
OFFICE
Certifi
ed that
appoint
Thiru /
ed to
Tmt /
Pensio Assistant Divisional Engineer
Selvi_
nable
______
service
______
and is
 Date :

Station : Highways , Construction & Maintenance

Kurinjipadi
Government
Aided Ednl. Institution
ANNEXURE – 1

APPLICATION FOR ADMISSION TO

THE TAMILNADU GOVERNMENT CONTRIBUTORY PENSION SCHEME
CPS
( G.O.Ms.No.430,Finance( Pension)
IndexDepartment
Number , 06-06-2004)
( To be furnished in Duplicate)

Particulars
N.VELVIZHI
S.No Details Male Female
1 Name of the Applicant Married Unmarried
2 Sex Road Inspector

3 Marital Status Office of the Assistant Divisional Engineer ,

Highways, Costruction & Maintenance ,
4 Official Designation Tamilnadu
KurinjipadiMinistrial Service
Office to which attached 23.10.2013 F.N
5

6 Service to which the Applicant Belongs Government

7 Date of First entry into service 5200-20200-2000

Whether appointed in Govt. / Aided Educational 5200+2000

8 Institution
9 Scale of Pay 06.05.1977

10 Basic Pay 31.05.2035

11 Date of Birth Regular

12 Date of Superannuation Yes No

Whether appointment is regular or Rule 10(a)(i) of the SC
13 General Rules for the state and Subordinate Service.

14 Whether recruited for Pensionable Service

15 Community of the Applicant Saroja

16 Details of Nomination 70
(a) Name of the Nominee Mother
(b) Age Plan-1 / Plan-2 / Plan-3
(c) Relationship

17 C.P.S. Plan opted**

18 Remarks, if any

Station:
Date :
Signature
TO BE FURNISHED BY THE of THE
HEAD OF the Applicant
OFFICE
Certifi
ed that
appoint
Thiru /
ed to
Tmt /
Pensio
Selvi_
nable
Date :

Assistant Divisional Engineer

Station : Highways , Construction & Maintenance
Kurinjipadi
 06.05.1977

on scheme
2039
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