Application for the grant of special increment in the form of

 personal pay for promoting Small Family Norm by undergoning

 sterlisation operation on or after 04.12.79 (Authority:Bd's

 letter No.80/H(FW)7/1 of 7.2.80)

 

 Employee's Name :                                Male/Female        

 Emp.No.         :

 Designation     :

 Office/Shop/T.No.:                   

 Sterilisation done :         Tubectomy/Vasectomy

 Date of Operation:              Hospital's Name:

 Place of Hospital:                    Design. of the Doctor

                                       issuing the certificate

 Employee's Age:                      

 Spouse's age:               

 Name of the Spouse:                No.of living children:

 Scale of pay:                 Pay drawn:                         

 Date of next increment:

 Rate of next increment:               If spouse is employed in Govt./

                               Quasi Govt./Govt.Enterprises:

 Designation:                Place of Employment:

 

 

                                  Address of the employer

                                  of the spouse.

 

                                      DECLARATION TO BE FURNISHED

                              ---------------------------

1. I have undergone Vasectomy/Tubectomy sterlisation at the Hospital

2. My spouse Shri/Smt.                      has undergone Vasectomy/

   Tubectomy sterlisation at the Hospital                          on 

3. The necessary certificate issued by                        in the

   proforma prescribed in Board's letter no.80/H(FW)7/1 of 05.06.81

   is enclosed.

4. In case recanalisation is resorted to by myself or by my spouse

   for any reasons whatsoever, I undertake to report this fact

   forthwith to the Government so that the payment of special

   increment sanction is stopped from the date of recanalisation.

5. I also certify that my wife Smt.                       is not

   pregnant on this date (applicable Tubectomy/Vasectomy only)

6. My spouse is not employed.

7. My spouse is employed as                    at the office of

   I                            hereby declare that my spouse is

   not claiming the benefit of special increment in his/her office.

   The declaration furnished by my spouse in this regard is

   enclosed (in dup.).  The sanction of special increment to me

   may be advised to my spouse's employer and to the Accounts Officer

   concerned.

8. I declare further that I will not make a second claim for special

   increment if Vasectomy/Tubectomy is undergone by myself of by

   my spouse at a later date. My spouse also will not resort to this.

9. I also certify that the above particulars furnished ny me are

   true and correct to the best of my knowledge.

 

Place:

Date:                                    Signature of the employee.

 

Forwarding endorsement to be made by the supervisor:

----------------------------------------------------

In case Free pass is issued to the employee at his end

Emp.Name:                      Design:              Emp.No.

Spouse Name & Age:                   No.of Living children:

 

       The above particulars are furnished as per the pass

declaration furnished by the employee.

2. In case of others:-

    The application is forwarded for further action.

                   Forwarded to by Dy.CPO/G /Dy.CPO/WS

 

 

Date:                            Signature of the forwarding official

                         with designation office/Shop.

                                      DECLARATION TO BE FURNISHED

                              ---------------------------

1. I have undergone Vasectomy/Tubectomy sterlisation at the Hospital

 

2. My spouse Shri/Smt.                      has undergone Vasectomy/

   Tubectomy sterlisation at the Hospital                          on 

 

3. The necessary certificate issued by                        in the

   proforma prescribed in Board's letter no.80/H(FW)7/1 of 05.06.81

   is enclosed.

 

4. In case recanalisation is resorted to by myself or by my spouse

   for any reasons whatsoever, I undertake to report this fact

   forthwith to the Government so that the payment of special

   increment sanction is stopped from the date of recanalisation.

 

5. I also certify that my wife Smt.                       is not

   pregnant on this date (applicable Tubectomy/Vasectomy only)

 

6. My spouse is not employed.

 

7. My spouse is employed as                    at the office of

   I                            hereby declare that my spouse is

   not claiming the benefit of special increment in his/her office.

   The declaration furnished by my spouse in this regard is

   enclosed (in dup.).  The sanction of special increment to me

   may be advised to my spouse's employer and to the Accounts Officer

   concerned.

 

8. I declare further that I will not make a second claim for special

   increment if Vasectomy/Tubectomy is undergone by myself of by

   my spouse at a later date. My spouse also will not resort to this.

 

9. I also certify that the above particulars furnished ny me are

   true and correct to the best of my knowledge.

 

Place:

 

Date:                                    Signature of the employee.

 

Forwarding endorsement to be made by the supervisor:

----------------------------------------------------

In case Free pass is issued to the employee at his end

Emp.Name:                      Design:              Emp.No.

 

Spouse Name & Age:                   No.of Living children:

 

       The above particulars are furnished as per the pass

declaration furnished by the employee.

 

2. In case of others:-

    The application is forwarded for further action.

                   Forwarded to by Dy.CPO/G /Dy.CPO/WS

 

 

 

 

Date:                            Signature of the forwarding official

                         with designation office/Shop.