SCHEDULE III

FORM I
(See Rule 24 - A)

APPLICATION FOR ‘ IDENTITY CERTIFICATE’ FOR APPLYING FOR

GRANT/RENEWAL OF PASSPORT /AND ‘NO OBJECTION CERTIFICATE TO
NDERTAKE FOREIGN TRIP

(To be filled by the applicant)

1. Name, designation, office address & scale :

of pay (if selection grade, or special grade
indicate respective ordinary grade scale of
pay)

2. Date of retirement :

3. Name of countries proposed to visit and :

duration (need not be filled up to obtain
passport to seek employment abroad)

4. Purpose of visit :

5. Source of funds to meet the cost of the :

proposed foreign travel

6. State whether any criminal prosecution is :

contemplated or pending against you and
whether your presence as witness would
be needed in any criminal case under
investigation or trial.

CERTIFICATE

I undertake that I will uphold the honour and dignity of our Nation and will not
indulge in any act prejudicial to the integrity and sovereignty of our country during my
travel and stay abroad.

SIGNATURE OF THE APPLICANT

/counter sign /
by head of the Institution
 (TO BE FILLED BY THE HEAD OF THE DEPARTMENT)

7. Are the particulars furnished by the :

applicant correct as per information
available with the department?

8. Whether the presence of the applicant :

outside India, may or likely to prejudice
the friendly relations of India with any
foreign country.

9. Whether the applicant at any time during :

the period of five years immediately
preceding the date of his application,
been convicted by a court in India for
any offence involving mortal turpitude
and sentenced in respect thereof to
imprisonment for not less than two
years?
10. Whether any proceedings in respect of :
an offence alleged to have been
committed by the applicant are pending
before a criminal court in India.

11. Whether any warrant or summons for :

the appearance or warrant for the arrest
of applicant has been issued by a court
under any law for the time being in force
or whether an order prohibiting the
departure from India of the applicant has
been made by any such court.

12. Whether the applicant has been :

repatriated and has not reimbursed the
expenditure incurred in connection with
such Repatriation.

13. Whether any Government dues are :

pending recovery,. If so., the details
thereof.

14. Whether any disciplinary action is :

pending under Rule 17(b) of the Tamil
Nadu Civil Services (Discipline &
Appeal) Rules.

15. Whether a certificate has been obtained :

from Special Branch CID (security) that
the applicant does not figure adversely
on the security records of the
Government.
16. Whether any corruption charges or :
vigilance enquiry is pending against the
applicant.

17. Is there any contractual obligation to be :

discharged by the applicant (applicable
in case of travel for employment only)

18. Recommendation of the Head of the :

Department.

SIGNATURE OF THE HEAD OF THE DEPARTMENT

/counter sign /
by head of the Institution
 ANNEXURE – I

PROFORMA PARTICULARS TO BE FURNISHED BY MEDICAL OFFICER WHILE

APPLYING FOR NO OBJECTION CERTIFICATE / LEAVE OUT OF INDIA.

1. Name and Designation :

2. Whether he / she had obtained passport :

on any earlier occasion

3. Purpose of visit abroad :

4. Countries proposed to be visited :

5. Whether the proposed visit abroad :

is her first visit out of India. If not give
particulars of earlier visit and purpose of

6. Proposed date of departure and period of :

Visit

7. Whether visit will be undertaken at :

his own cost

8. Whether he/ she has executed a bond prescribed:

for the purpose (If he is applying for leave)

The particulars furnished the above or true to the best of my knowledge and
belief and that I have not given any false information purposefully or suppressed any
information.

SIGNATURE OF THE APPLICANT.

/counter sign /
by head of the Institution
 CHECK LIST
PARTICULARS TO BE FURNISHED TO GO ABROAD ON SHORT VISIT ON
OWN EXPENSES.
NOTE: Written application of the Medical Officer / applicant to be submitted at least two
months’ prior to the visit (in duplicate) unless otherwise it is on emergency and due
to extra ordinary situation which should be vouched by the forwarding authority.
1.Application of the Medical Officer / applicant :
requesting permission to Leave Out of India
indicating the following:-

a) the country to which the visit is made :

b) reason for the visit :

c) the period of absence specifying the dates
for which leave is required :

d) whether valid passport is on hand with the

applicant or not (Give passport Number) :

e) the proposal for issue of No Objection

Certificate (NOC) to go abroad should reach
this office two months’ in advance from the
Date of proposed journey :

f) whether the medical officer is having private

practice and if so the income derived from
private practice should also be shown by the
medical Officer in the income-tax statement
for the particular year in which the proposed
journey to be performed by him. :

g) source from which the expenditure for the

proposed visit met by the medical officer :

h) certificate to the effect that the proposed

visit by the medical officer is the first /
second visit during the calendar year :

2.Annexure I and II duly signed by the Head of

Institution (induplicate) :

a) whether applicant is a Self Drawing Officer :

3.Leave Eligibility Report by the Dean /
Head of Institution :

(NOTE: In case of Self Drawing Officers it may be

obtained by the O/o the Director of Medical
Education from Accountant General’s Office)
4.Service details is in the prescribed format
(in duplicate) copy enclosed attested by the Dean :

5.Certificate by the Head of Institution that no

disciplinary case is pending against the medical
officer / applicant. :

6.Certificate by the Head of Institution that no

Govt. money is due from the medical
officer / applicant. :

7.Certificate by the Head of Institution that

applicant have no subsisting contractual
obligation with the Government :

8.Attestation form in duplicate duly filled in. :

9.Declaration by the applicant that no case is

pending against him / her if any court of law,
with the attestation of the signature by the
Head of Institution :

10.Whether Service Register of the applicant

enclosed with the proposal for permission
for leave out of India :

11.Whether passport copy duly attested by the

Gazetted Officer enclosed for applying for
Renewal of Passport and leave out of India :

Assistant Office Superintendent Administrative Officer Dean

NOTE: THE APPLICATION WITH THE ENCLOSURES SHOULD BE NUMBERED

SERIALLY THE NUMBER OF THE PAGE SHOULD BE NOTED AGAINST EACH ITEM
(PARTICULAR / ENCLOSURE / CERTIFICATE ETC.) IN THE CHECK LIST. THE
SIGNATURE OF THE APPLICANT SECTION SUPERINTENDENT AND THE JUNIOR
ADMINISTRATIVE OFFICER / ADMINISTRATIVE OFFICER AND THE DEAN MUST BE
OBTAINED AT THE END OF THE CHECK LIST.
 PROFORMA

SERVICE PARTICULARS FOR ISSUE OF NO OBJECTION CERTIFICATE AND

CLEARANCE BY VIGILANCE DEPARTMENT.

1. Name and designation of the Officer :

2. Father’s Name :

3. Date of birth :

4. Date of enlisting in Govt. Service :

5. Post held and places served during the :

5 Years

6. Whether he / she is facing any enquiry :

on the basis of the Directorate of Vigilance
and Anti Corruption report

7. Date of Retirement :

8. Date of going abroad :

DEAN / HEAD OF THE INSTITUTION

 ATTESTATION FORM

1. Name in full & Designation :

2. Father’s Name :

3. Present Address :

4. Home Address :

5. Date and place of birth :

6. Education qualification showing places of education with year in School, since 15th
year of age.

Name of School Date of Entering Date of Leaving Examination

with full Address Passed
Address where the candidate has resided for more than one year during the proceeding
five years.
From To

(1) (2) (3)

8. Particulars of previous employment if any held:

Full address of Designation of Last pay Period

Reasons
Office firm or post held or drawn From To for
Institution description of resignation

SIGNATURE OF THE APPLICANT.

/counter sign /
by head of the Institution
 DECLARATION

I, ___________________________________________________________ hereby
declare that there is no case pending against me in the Court of Law or any Vigilance
enquiry is being pending / contemplated / executed and I have no contractual obligation to
be fulfilled.

SIGNATURE OF THE APPLICANT

/counter sign /
by head of the Institution
 ANNEXURE – II

PARTICULARS TO BE FURNISHED BY THE HEAD OF THE DEPARTMENT

1. Name of the Applicant & Designation :

2. Whether the request of the Medical Officer :

“No Objection Certificate” for obtaining
passport and for Leave out of India and or
found to be bonafied.

3. Whether any disciplinary action of :

Vigilance Enquiry is pending or contemplated
Against the Medical Officer and whether
There are any grounds to believe that the
Medical Officer could figure adversely in
The Security Records of the Government

4. Whether grant of No Objection Certificate :

to Medical Officer to obtain passport is
recommended

5. Whether the Medical Officer has any :

subsisting contractual obligation to
fulfill the Government

6. Whether request of Medical Officer :

for Leave out of India is recommended and
if so the period for which leave is to be
sanctioned and nature of leave

7. If Leave out of India is recommended

whether the bond executed by the
Medical Officer is in order and whether it :
Has been accepted by Head of the Department

Signature of the applicant Signature of the Head of Department

/counter sign /
by head of the Institution
 B.UNDERTAKING TO BE GIVEN BY APPLICANT

During my visit abroad, I shall not take up any appointment or undergo any training or
study programme abroad without the prior approval of the Government.

The Government will not be liable for any expenditure, including travel expenditure, etc.
in connection with the visit abroad.

I will not tender resignation of my appointment under the Government, while

abroad, I am aware that the Government not accept my resignation if tendered which I am
on leave abroad.

I shall not canvass or seak any business abroad.

Bearing unforeseen circumstances, I will not stay abroad beyond the period for which I
am granted leave out of India.

The passport that will be obtained on the basis of the No Objection Certificates that will
be issued to me on the basis of the undertakings) will be utilized for any subsequent visit
abroad without the prior permission of the Government.

I have executed a bond prescribed for the purpose of grant of leave out of India and I
shall abide by the condition of the bond.

I shall proceed abroad only after the leave Out of India is sanctioned to me by the
Government and Only after obtaining proper relief.

SIGNATURE OF APPLICANT.
/counter sign /
by head of the Institution
 CHECK SLIP

AS PERSCRIBED BY THE GOVERNMENT

Granting of no objection certificate to leave abroad

1. Whether Service Book of the Medical Officer is enclosed :

2. Whether Xerox copy of passport is enclosed :

3. Whether copy of latest income tax return is enclosed :

4. From the time of joining in Government service how many

times has the application gone abroad :

5. Private Visits Dates Expenditure

beyond places of visits From To :

Official Visits Dates :

beyond places of visits From To

6. Whether necessary entries have been made in the :

Service Register

7. Current visit-Expenditure met by whom :

8. Correlate with the income Tax Statement :

9. Proof of purchase of tickets through their source : --

Head of Institution. Director of Medical Education.

 APPLICATION FORM FOR OBTAINING NO OBJECTION CERTIFICATE

1. Name of the application, his rank and unit :

which he/she is attached

2. Name of the countries proposed to be visited :

3. Duration of stay :

4. Purpose of Visit :

5. Address of relatives friends, if any with whom :

the applicant proposed to stay while abroad.
6. The probable expenditure for the journey to :
these foreign countries and how he will meet it.
If the expenditure for such journey is proposed
to be met by other a consent letter to that
effect from the person concerned.
7. Whether he has already visited any foreign :
countries and if so, particulars thereof
8. The Month and year of the proposed visit :

9. Length of Service of the person concerned :

with the date of appointment
10. Amount of credit of the subscribers GPF :

11. Applicant's assets furnished to Government :

12 Applicant is an income-tax payee, if so, any

due to Government

CERTIFICATE
Certified that I will not stay in the foreign countries, I will return within the period
specified.

Signature of the applicant.

/counter sign /
by head of the Institution
 CERTIFICATE

1. This is to certify that ________________________________________ he/she

has no disciplinary case is pending/ contemplated against him.

1. 2. This is to certify that ________________________________________he/she

has no Government money is due to be recovered from him.

Head of Institution
 FORM II

IDENTITY CERTIFICATE AND NO OBJECTION CERTIFICATE TO APPLY FOR GRANT/

RENEWAL OF PASSPORT
(To be given in Duplicate)
(See Rule 24-A)

Under rule 24-A of the Tamil Nadu Government Servants Conduct Rules, 1973, it

is Certified that Thiru/Tmt/Selvi Son / wife /daughter of Thiru

who is a temporary / permanent employee of this from and is at

present holding the post of Thiru/Tmt/Selvi who is

also an Indian national, is / are a dependent family members of Thiru/Tmt and

his/her identity is certified. This Department has no objection to his / her acquiring /

renewal of Indian Passport, Subject to the following conditions, namely :-

i) that the individual should not take up any appointment or undergo any training other
than the one specified, if any or study programme during his/her stay abroad without
prior approval of the Government/Head of the Department.

ii) that the Government / Head of the Department will not be made liable for any
expenditure including travel expenditure etc., in connection with his/her trip abroad.

iii) that he/she should not tender resignation of the post held by him/her under this
Government while abroad and his/her resignation of appointment will not be accepted
on any account.

iv) that he/she should not canvas or seek any business while abroad.

v) that before proceeding abroad, he/she should apply to the Government/ Head of the
Department for the sanction of leave to which he/she is eligible and get it sanctioned
for the entire period of his /her absence.

vi) that he/she shall not use the passport obtained on the basis of the “Identity Certificate”
for any subsequent trip abroad for any purpose without the prior sanction of the
competent authority and

vii) that the “Identity Certificate” will be valid only for a period of six months from the date
of issue.
 The undersigned is authorized to sign this “Identity Certificate No Objection
Certificate” I have read the provisions of sub-section (2) of section 6 of the passports Act,
1967 and certify that these are not attracted in the case of this applicant. I recommended
issue of an Indian Passport to him/her, it is certified that, this Department is a State
Government Department. The identity card Number of , Pan Card No.
is …

Reference No. and Date Name , Designation and

Address, telephone No.

Applicant’s photo to be attested by the certifying authority