1. Name of Subscriber :

2. Father's /Husband 's Name

3. Date of Birth of Subscriber

4. Date of Joining of service of Board

5. Designation

6. Basic pay

7. Monthly rate of subscription to commence i.e after one year of the date of joining

8. Month from which subscription to commence i.e after one year of the date of joining

9. D.D.O with whom working

10. Remarks

                                           Signature of Subscriber

NOTE : This application should include the following :-

1. nomination in respect of GPF , Death -cum-Gratuity and GIS duly filled in and verified by the DDO concerned in triplicate.

2. List of family members duly signed by the subscriber and verified by the DDO concerned, in triplicate.

Certificate from DDO.

It is hereby certified that particulars given in the above application form, nominations and list of family members are correct as per records and nothing has been concealed therein.

Signature of DDO

(To be filled in at Head quarter) Above particular have been checked and found correct. GPF A/C No. ____________ may be allotted

AAO SAO/AO

A/C No. _______________________ alloted SAO/AO DDO