From

To
The Commissioner,
Indian Medicine and Homoeopathy Dept.,
Chennai-106.

Through Proper Channel

Sir,

Sub:

---------

I would like to apply for the Passport to

In this regard, I humbly request The Commissioner, Indian Medicine
and Homoeopathy, Chennai to issue No Objection Certificate to apply for the Passport. I have
enclosed herewith the Necessary forms for your kind perusal and further proceedings.
Thanking You
Yours faithfully,

Encl:
1. Form-I & Form-II
2. Service particulars
 "SCHEDULE - III
FORM - I
( See rule 24 – A )

APPLICATION FOR "IDENTITY CERTIFICATE" FOR APPLYING FOR GRANT /

RENEWAL OF PASSPORT/AND 'NO OBJECTION CERTIFICATE' TO UNDERTAKE
FOREIGN TRIP
( To be filled by the applicant )

1 Name, designation, office :

address and 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 : - No -

prose-cution 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 honor 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.

 (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 moral
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 and Appeal) Rules.

15 Whether a certificate has been :

obtained from Special Branch
C.I.D. (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 District Siddha Medical Officer

PROFORMA PARTICULARS TO BE FURNISHED BY THE GOVERNMENT
SERVANT WHEN APPLYING FOR NO OBJECTION CERTIFICATE TO LEAVE OUT
OF INDIA.

1 Name and Designation :

2 Whether he had obtained : No

passport on any earlier occasion.

3 Purpose of visit abroad :

4 Countries proposed to be visited :

5 Whether the proposed visit : Yes

abroad is his first visit out of
India. If not, give particulars of
earlier visits & purpose of visit.

6 Proposed date of departure & :

period of visit.

7 Whether visit will be undertaken :

at his own cost.

8 Whether he has executed a bond : Yes

prescribed for the purpose, if he
is applying for leave?

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

Signature of the applicant

 SERVICE PARTICULARS

1 Name :

2 Spouse Name :

3 Date of Birth & Place :

4 Present Address :

5 Permanent Address :

6 Date of Entry into Govt. Service :

7 Service Particulars : Furnished below

8 If any disciplinary case is : - No -

pending

Sl. Period
No. Designation Place of working From – To

1.

District Siddha Medical Officer

 CERTIFICATE

This is to certify

, is not having subsisting contractual obligation with the Government and there is no

disciplinary case pending or contemplated against his and he is having

------------------------- of Earned Leave in his credit as on date.

District Siddha Medical Officer

 DECLARATION

hereby declare that I have not been involved in any Civil or

Criminal case and there is no case pending against me in any Court of Law.

Signature of the applicant

 DECLARATION

This is to certify that ,

is not having any due to Government

as per the records available.

District Siddha Medical Officer

 FORM - II

IDENTITY CERTIFICATE TO APPLY FOR GRANT/RENEWAL OF

PASSPORT
(To be given in Duplicate)
(See rule 24-A)

Certified that Thiru/Tmt/Selvi--------------------------------------------------------------------

son/wife/daughter of Thiru.___________________is a temporary/permanent
employee of this
_____________________(Office address) from ______________(date) and is at present
holding the post of
_______________________________________________________.
Thiru/Tmt./Selvi._______________________________is a dependent family member of
Thiru/Tmt_______________________________________________and his/her identity is
certified.
This Department has no objection to his/her acquiring 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 traveling 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 canvass 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 "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
recommend issue of an Indian Passport to him/her. It is
certified that this Department is a State Government Department. The Identity
Card Number of
Thiru/Tmt.(employee) ________________________________is ______________.
Reference No. and Date
Name,
Designation and address
Applicant's photo to be Telephone No.
attested by the Certifying
Authority.