NAME OF HOD / NODAL OFFICER (with designation) :____________________________ DEPARTMENT NAME: ___________________________________

OFFICE NAME : ____________________________________MOBILE NUMBER of HOD / NODAL OFFICER: _______________________________________

OFFICE ADDRESS : _________________________________________________

S. Employee Father/ Designation Pay Spl Basic Pay Group Reserved Qualification Voter ID Sr.No. Booth Home Posting
N Name Husband Matrix Pay in the Pay (A,B,C, Category (Epic) of Vote No. Assembly Assembly
o. Name / FPL/ (if Matrix D etc.) (General, No. with /Part (Assembly (Assembl
ACPL any) BC,SC, assembly No. where Present y where
No. etc) name Vote Residence is Present
located) office is
located)
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Native Present Address Mobile Date of Date of Retirement Gazatted Ad Hoc? Female Handicapped Having Service Having BLO
Assembly Number Birth Joining Date ( yes /no) (yes/no) (yes/no) (yes/no) earlier period<3yr? EVM (yes/
(Assembly Election (yes/no) Training? no)
by Birth) Duty? (yes/no)
(yes/no)

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