PROFORMA – I

OFFICE INFORMATION
(To be submitted in triplet)
STATE GOVERNMENT

CATEGORY: CENTRAL GOVERNMENT

OFFICE CODE:
(As Per Lok Sabha (TickAny One)
Election -2024) STATE PSU

CENTRAL PSU

1. OFFICE NAME :……………………………………………………………………………………………………………………………….

2. DEPARTMENT NAME : ………………………………………………………………………………………………………………………………

3. DESIGNATION OF OFFICE HEAD : ……………………………………….…………………… DDO Code (If any)……………………………………

4. MOBILE NUMBER : ………………………………………………………………………………………………………………………………

5. FULL ADDRESS : ..…………………………………………………………………………………………………………………………….

……..…………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………..

6. BLOCK NAME ………………………………………………………………………………………………………………………………….

7. ASSEMBLY CONSTITUENCY NUMBER : ……………………………………………………………………………………………………………………………….

AND NAME(WHERE OFFICE SITUATED) ……………………………………………………………………………………………………………………………………….

8. CONTACT NUMBER : STD Code :………………………………………NUMBER …………………………………………………..…

9. e-MAIL ADDRESS : ...…………………………………………………………………………………………………………………….…….

TOTAL EMPLOYEE WORKING/POSTED

MALE FEMALE OTHER TOTAL

TOTAL CONTRACTUAL EMPLOYEE WORKING/POSTED

MALE FEMALE OTHER TOTAL

Certified that the information given above is true and based on actual fact. Verified
Performa – II of all officers/staffs working/posted under this office/department are attached. No
officers/staffs name has been left.

Dated : Signature of Head of the office

with seal
 EMPLOYEE INFORMATION
PROFORMA – II
Paste Recent
(To be filled using English CAPITAL LETTERS only)
Colour Passport
*PIN Number (As Per Lok Sabha 2024) - __________________________
Size Photo

OFFICE NAME: ____________________________________

1. EMPLOYEE NAME: _______________________________________________________________________

2. DESIGNATION: _______________________________________________________________________

3. SEX MALE FEMALE OTHER

4. SALARY DETAILS GRADE: _____________BASIC PAY:______________ Pay Matrix Level: __________________

(Note: Fill contractual in case of contractual employee in Grade)

5. DATE OF RETIREMENT: ___________________________

6. POSTING BLOCK NAME: _________________________________________________________________________

7. MOBILE NUMBER: _________________________________________________________________________

8. BLOOD GROUP Group Rh factor (+/-)

9. PRESENT RESIDENTIAL ADDRESS: ____________________________________________________________________

10. HOME BLOCK NAME: _______________________________HOME DISTRICT: ________________________________

FILL BELOW THE NUMBER AND NAME OF ASSEMBLY CONSITUENCY (AC) WHERE –

AC No. AC Name
11. POSTED

12. HOME

13. PRESENT RESIDENCE :

AC Name:
14. YOUR NAME IS ENROLLED Part Number:
Sr. No. in Voter List:
Booth No.
Booth Name:
EPIC No.

OTHER DETAILS _
15. Bank Detail:- Bank Name Bank Branch
IFSC code Account No.

16. IS POSTED FOR 3 YEARS OR MORE IN THE LAST 4 YEARS IN THE SAME DISTRICT : YES NO
17. DATE OF JOINING IN THE DISTRICT: _____/_____/_______
18. Is BLO : YES NO If Yes Then BLO AC Name ______________ Part No.
__________________________
19. Is PwD (Person with disability) : YES NO If Yes Then % ______________
20. Is Teacher: YES NO
21. Is Gazetted Officer : YES NO
22. REMARKS : _______________________________________________________________________________________

Signature of Head of the office with seal