Fill - FORM OF APPLICATION FOR DISABILITY PENSION: 1. Name

FORM A

FORM OF APPLICATION FOR DISABILITY PENSION

1. Name of the applicant and full Office address

2. Father's name

4. Present or last employment, including full

particulars and address of the Establishment

3. Full Residential address (showing village, Post

Office, District, State)

5. Date of entry into service

6. Full particulars of service and length of service,

including interruption (both qualifying and non-

qualifying)

7. Percentage of Disability sustained due to Injury /

Disease (as certified by the Medical authorities)

and circumstances which resulted in that disability

8. Pay at the time of injury sustained, disease

contracted (as certified by the Medical Authorities)

10. Date of injury/disease (as certified by the Medical

Authorities)

9. Pension claimed

11. Place of Payment

12. Other relevant information, if any

13. *Date of applicant's birth by Christian era

14. Height

15. Identification Marks

16. Thumb and finger impression :

* If not known exactly, please state on the best information or estimate and according to the best of your

knowledge and belief.

NOTE. - Thumb and finger impressions and particulars of height and personal marks are not required to be

given by such ladies, Gazetted Officers, Government titile-holders and other persons as are specifically

exempted, by the Government by special orders in that behalf.

Place

Date on which the

applicant

applied for pension:

Applicant

Head of Office

Date

Thumb..............................................Fore-finger...................................................

Middle finger.........................................

Ring-finger........................................Little-finger..................................................

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