REGISTRATION & ISSUE OF IDENTITY CARD

FORM FOR EX-SERVICEMEN

1. Number ________________ 2. Rank _______________

3. Regt/Corps __________________ # Trade _______________# Last Unit ________________

4. Name ____________________________________

5. Father's Name ___________________________

6. Educational Qualification:

Civil ___________________ Service __________________
       ___________________              __________________

7. Decoration _________________ 8. Character ______________________

                                                         # Med Category ________________

9. Address                                       # Tele No: _______________________ _______________________________________________________________
_______________________________________________________________
_______________________________________________________________

# Original Native State ________________ # Proficiency in Gujarati __________ (Yes or No)

10. Religion________________________ 11. Caste_____________________________

12. Details of family (wife, dependent children up to 25 years and dependent parents)

13. Date of Birth ___________________ 14. Date of Enrollment ________________

15. Date of Discharge _______________ 16. Reason for discharge ________________

17. Amount of Pension (a) Service Pension Rs. _________________

18. Lump sum payment received:

(a) Gratuity Rs.____________    (b) Group Insurance Rs. _________________

(c) Leave encashment Rs. _____________________

(d) Financial Assistance Rs. _____________________

19. Commuted Pension Rs. ___________________

20. Discharge Book No and date__________ 21. PPO NO. and date _______________

22. Present occupation & monthly income

Service Rs. __________________ Business/Industry Rs. _________________

Agriculture Rs. _________________ Un-employed _________________________

23. Other relevant information, if any ________________________

24. Identification Marks ________________________________

25. Left Thumb Impression ________________________________

DECLARATION

I hereby declare that the particulars given above are true to the best of my knowledge and belief.

Date :

Place:                                                              (Signature of the Applicant Ex-serviceman)

VERIFICATION

The above Ex-Serviceman falls in the category of ex-Serviceman. The Identity Card No GUJ/0__ / ______ Dated__________ is prepared for issue to the individual after due verification & signature or the DSWRO.

Date:

Place:                                                                          (Signature of staff verifying Details & preparing ID card)

COUNTER SINGED

Date:

Place:                                                                                                                           (Signature of DSWRO)