Affix (not to pin or

staple) the passport

size photo here

TO BE FILLED (IN DUPLICATE) IN BLOCK LETTER

1 Name of the Official Dr.NAGATANOOJ

2 Employee No. 101924

3 Date of Birth 28-10-1981

4 Date of Appointment 02-07-2009

5 Designation I.M.O. Grade 1

#90, 14th Cross, Muneshwaranagar,Ullal main

6 Present Residential Address
road,Bengaluru. 560056

7 Permanent Address Same as above

8 Telephone/Mobile No. (if any) 9738028018

9 Blood Group B Positive

10 Identification Mark Scar on the nose

 Signature:

Name:

Date: Designation:

EMPLOYEES' STATE INSURANCE CORPORATION

MODEL HOSPITAL
Rajajinagar, Bangalore-560 010
Ministry of Labour, Govt. of India
e-mail:esicmh@gmail.com
Ph. No.23325130/23320271 Fax:23325130
 Affix (not to pin or staple) 2-B
size photo with white
background here

FAMILY DECLARATION/PARTICULARS UNDER CS(MA) RULES, 1944

Name of the official: ____________________________ Designation: _________________________ Employee No.:_____________

Date of Birth:________________ Date of Appointment:_________________ Home Town: _____________________
Details of the members of the family as on date:
If employed/retired in/from
Sl.
Relationship with Pvt./Govt. (Name of the Retired Parents
Name of the Members of the Family Age & Date of Birth Monthly Income
the Official Organization/Institution etc. Monthly Pension
No.
with designation)

8
I hereby undertake that the above said members of my family are residing with me as on date:
Signature:

(Name in Block Letters)

Place:
Date: Designation:

Note: 1) Particulars in respect of brothers aged more than 18 years and married sisters are not necessary.
2) All the columns should be filled compulsorily falling which the settlement of bills will cause delay.
3) False declaration is liable to attract provisions of CCS (CCA) Rules.