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    Application Cashless Pen

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    suvidhamkg

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    © All Rights Reserved
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    Application Cashless Pen

    Uploaded by

    suvidhamkg
    4 views1 page

    Original Title

    Application_Cashless_Pen

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    Copyright:

    © All Rights Reserved
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    4 views1 page

    Application Cashless Pen

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    suvidhamkg

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    © All Rights Reserved
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    of 1

    APPLICATION FORM OF GOVERNEMNT PENSIONER/FAMILY PENSIONER

    hEZt^dE'>,>d,&KZ>>DW>Kz^EWE^/KEZ^^,>^^D/>
    TREATMENT SCHEME, 2014
    
    Pensr. Last Off. DDO- SUB-DIVISIONAL OFFICER, MEKLIGANJ, ( COEHMA001 ) (DRAWING AND DISBURSING
    OFFICER), DEPARTMENT OF DDO-HOME DEPARTMENT
    DETAILS OF EX-GOVERNMENT EMPLOYEE: WB/PEN/15/000135620
    1. NAME OF THE EX- GOVERNMENT EMPLOYEE: RABINDRANATH BASU

    2. LAST DESIGNATION: DEPUTY MAGISTRATE

    3. ADDRESS: 8, Pankaj Roy Sarani, Deshbandhu Para, P.O.-


    Siliguri Town, Ps- Siliguri District- Darjeeling,
    Pin- 734004

    4. DATE OF BIRTH: 09/11/1958

    5. DATE OF RETIREMENT: 30/11/2018

    6. DATE OF DEATH(In Case Of Family Pensioner): NOT APPLICABLE

    7. MOBILE NUMBER: 9475393695

    8. PENSION PAYMENT ORDER NUMBER: 111837741

    9. EMAIL ID(IF ANY): [email protected]

    10. DATE OF ENROLLMENT: 01/12/2018

    11. NAME OF PENSION SANCTIONING AUTHORITY : PRINCIPAL SECRETARY

    12. OFFICE ADDRESS: OFFICE OF THE SUB-DIVISIONAL


    OFFICER, MEKLIGANJ, DISTRICT-
    COOCHBEHAR
    DETAILS OF PENSIONER WITH THEIR ELIGIBLE FAMILY MEMBERS:
    SL NO. Name D.O.B/AGE Relationship ID NO PHOTO SIGNATURE
    1 RABINDRANATH 09/11/1958,61 SELF 111837741/1/3
    BASU

    2 SARBARI BASU 12/07/1962,57 WIFE 111837741/2/3


    BISWAS

    3 RUPKATHA BASU 20/12/1993,26 UNMARRIED 111837741/3/3


    DAUGHTER

    1. I, HEREBY DECLARE THAT THE THE STATEMENTS MADE IN THE APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
    2. I FURTHER DECLARE THAT I SHALL ABIDE BY THE PROVISIONS OF THE SCHEME AS MAY BE IN FORCE FROM TIME TO TIME.
    3. I FURTHER DECLARE THAT I HAVE NOT OPTED OUT FROM THE SCHEME IN ANY PREVIOUS OCCASION.(EXCEPT PRIOR TO 29/08/2011 CASES)

    12/2/2019 5:57:13 PM Signature of the Applicant

    N.B. Please take two copies of print out of the Application Form with scan photo & signature of all beneficiaries as generated
    from the system to the DDO for verification.In case of a child below twelve years, natural guardian's scan signature with
    child's photograph is required.

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