FORM OF EXERCISING OPTION FOR CHARGE ALLOWANCE AS PER

GO(MS) NO.377(88)/96/FIN. DATED 6-05-1996.

I, ……………………………………………………………… ……... holding the post of Medical Officer in
charge, Primary Health Centre …………… ……………………………………………… ………………………………
…………. ………………. ……. District do here by claim charge allowance for the following period.

(1) From ……………….to………………………….for holding the post of medical officer in charge,

Primary Health Centre …………………………….as per order number …………………………………....
………………………………………………………..

(2) From ……………….to………………………….for holding the post of medical officer in charge,

Primary Health Centre …………………………….as per order number …………………………………....
………………………………………………………

Audit No:………………….

Place: Signature:

Date : Name and Designation

For Office Use Only.

Verified with relevant records in the office, He/ she is eligible for charge allowance

From 1)…………….to ………………………………

2)……………...to……………………………..

Place : District Medical Officer of Health,

Date :