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APPLICATION FORM FOR COMPASSIONATE APPOINTMENTS
(For Compassionate Appointment for Dependants of Government Employees
who died or retired on medical invalidation)
1. Full Name of the Applicant :
(In block letters)
2. Relationship of the Applicant to the
Employee who died or retired on :
Medical Invalidation
3. Name of the spouse :
4. Permanent Address :
5. Full Postal Address for correspondence :
6. Name of the Employee who died or
Retired on Medical Invalidation :
7. Designation :
8. Office in which the employee is
Working at the time of death or :
Retirement on Medical Invalidation
9. Date of Death and Place :
10.If the employee is retiring on medical
Grounds date of retirement (Necessary :
Documents should be enclosed)
11. Particulars of Family members of the
Applicant including the deceased employee/
Retired on Medical Invalidation
Age at the
Whether
Time applying Relationship
S. Name of the Educational married
For with the
No Family Member Qualifications or
compassionate employee
not
appointment
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12. Caste :
(Schedule Caste/Schedule Tribes
Backward caste/others)
13. Date of Birth of the applicant :
14. Financial Status of the family of the
Deceased employee/retired employee :
15. Educational Qualifications of the
Applicant :
Name of the Examination
S. Passed / Name of the Year of Marks
Percentage
No University passing /Grade
Or Board
16. Native place and Mandal ----------------,----------------- :
17. If any one of the family members is
Employed? If employed particulars of : Yes / No Page No.
Employment.
18. Have you registered your name in the
Employment Exchange? If registered : Yes / No Page No.
Name of the employment exchange.
Registration Number and date
19. Whether the following certificates enclosed : Yes / No Page No.
Or not
a) Death Certificate : Yes / No Page No.
b) Caste Certificate : Yes / No Page No.
(Issued by the Tahasildar)
c) Nativity Certificate : Yes / No Page No.
(Issued by the Tahasildar)
d) Proper Person Certificate
(Issued by the Tahasildar) : Yes / No Page No.
e) No objection certificate from the
Other family members : Yes / No Page No.
f) Income Certificate
(Issued by the Tahasildar)
g) Date of birth certificate of the applicant : Yes / No Page No.
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h) Certificates of Educational qualifications
of the applicant : Yes / No Page No.
g) If the applicant is spouse of the deceased
Employee declaration by the spouse : Yes / No Page No.
That she/he is not married again
i) Declaration by the family members that
None of the family members is employed : Yes / No Page No.
In State/Central Government
I here by declare that the information furnished above is correct
and no information which is correct is not disclosed.
Place :
Full signature of the applicant
Date :
CERTIFICATE
( To be issued by the Head of the Office at the time of death of employee or
retirement on medical invalidation)
After careful examination of the application, it is hereby recommended that
the applicant is eligible for employment under compassionate appointment or
medical invalidation
Signature & Designation of the
Head of the office with seal
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NO OBJECTION CERTIFICATE
We, dependant family members of Late____________________________
Designation_____________Office___________________________ have no
objection to Provide employment to ___________________________ s/o, d/o
_____________________under Compassionate Appointment.
Signature of family members
1.
2.
3.
GOVT ORDERS TO BE REFERED
1 GO MS NO 687 GAD 3-10-77(Main G O)
2GOMS NO1005 E&S DT 27/12/74
3 GO MS NO84 GAD 17/2/84
4 GOMS NO 427 GAD 1/7/91
5GOMS NO504 GAD30/7/80
6GOVT MEMO NO747 SER-A/92-2GAD 5/9/92
7 GOMS NO 577GAD30/10/91
8GOMS NO 400 GAD DT 12/9/96
9GOMS NO536 GAD DT 9/10/96
10. GOMS NO 350 GAD 30/7/99(MARRIED DAUGHTER)
11 GOMS NO 378 GAD 24/8/99( WHERE ABOUTS NOT KNOWN)
12 GOMS NO155 GAD24/11/2000( AIDED&MPL)
13GOMS NO203 GAD DT 27/4/02 ( REVOKE OF MEDICAL INVALIDATION)
14 GOMS NO480 GAD DT 26/11/02( NOT HIGHER THAN JA POST)
15 GOMS NO 661 GAD DT 23/10/08( MEDICAL INVALIDATION RULES)
16 GOMS NO113 Edn DT 06/10/09(COMPASSIONATEAPPOINTMENTIN
AIDED )
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