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PUNE DISTRICT SECURITY GUARD BOARD, PUNEPrescribe Form for Permanent Registration of Security Guard

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9. 3t~c;l,(l~ ~ ;riqFull Name of the Applicant

~. qJ1<'1i~ ~ ;riqFull Name of the Father

~.~ trnTPresent Address

'd, Cfffif«l Cf) I<'11q dtResiding Since

~. 1jOO ~ qrorAddress of Native Place

~. \1IrijC1I.f1~ :Date of Brith

~

Age

~Sex

t9,~:Place of Brith :

tJTCf

Village

~. Taluka

~District

~

State

t. ~ G6T ~ qlff1«1:

Address of Residance for the

last ten years

~. ~1&nfUrcptffiI'ffi '

Eductional Qualification

90, ~~ &Am: ~Physical Fitness: Hight (em.)

Cf\iA (~.i)Weight(kg.)

~ tR (W.~.)Chest Size (em.)

(Normal & Expanded)

~~~CIml?Any Defect in Eyesight?

qq. q)".S\1) Nationality

:?) t11f2) Religion

~} \jfRf3)Caste

CJ:? $>SGlI-J) ~ :Information of Family:

q. f4ql(6C1 / 3tf4QI(6C1:Married I Unmarried

=? $>SGlId)t>1~r<Mf-q1 oq~fuiJDetails of Family Members

3£.wSr.No.

;:ncr

Name

~ ;mtAge Relation

~Q,(11~

Occupation

QffiT

Address

CJ~. ~luftGlluft~~ ~i"Ull~ft ~ mtRfT $ CJ)

3£~TT~u~Id)t>1 cWr ~ 3mCIT~~, qffi q ~J\'f"I"1~Names, Address and Phone No.: =?)of two relaives fo friends in Pune

who can be contacted in case of emergency

CJ'd. ~mCfWr~?~qm:q CPIt>1IQ~

Previous Work Experience withAddress and Duration

3£) ~&IT ~~ CfWrCP'(U~I,{11d1~~ft~ fct~wtff.ffiT~ ~?\3GT. ~ fcfRIT ~afUT t\

~ 3mCITq)<fu:r~," s~ rdCPluft~

~ 3t,{1~.1'<1 ~ ~a) Do you possess any special qualificationto work a Security Guard? e.g. - ifWorked

in MilitaryI Defence of Police I Civil DefenceDent \f ves aive Details

if) 31Jq17Jffi CR ~ 4>~~1 ~ ~~ ~ ~ CI',(u~ld 3Iffi ~~?(3t,<"I~1'<1(fq"~fu;r~)AreyouretrenchedordismissedfromtheaboveDept.(Ifyes, give details)

cp) 3TIQ"UT4>'6141'<1"1~MT ~~ ~ cpfur ~ :

q CI')UI~I~? cpfur 3t'<1~~1 q '> \:'I~ ~...: ~ ( ~\J1~.fh:f\) q Iil<>lCl'i-cl'1~, Cl'I<>Ilq~

.,.~ ~..Q.. ~ f""\.{:\tRIT q U1~""4I'1 ~IiIUI4.::t »1I1UIQd.,

~mcftWm~~.Since how long you have beenworking in :this profession and in which category?Give the Names and Addresses of the

Agencies and Employers with whomyou had worked or are in service, and detailsregarding the Experience and Payment etcEclode Proof if any.

~) 3TIQ"UT ~MT~~ ~ ~8fOT ~ ~ :~ ? ~. ~ ~1~l1'41, ~1i)4-q1,(, 3t'<1~1,(1

~ meRCfmCI1.

Have you undergoan training as a

Security Guard? e.g. Fire Fighting, First aid etc.

if yes give details and submit documentaryevidence.

<\~. ~ ~ ;riq ~ 3t'<1~1,(1 ~).scr<lld ~ :If the applicant ever changed his / her name:

if yes, give details

<\fc. . 3tuf~I,(I.) 41,(141c!tTRUT~ ~ cnr?Whether the applicant have obtained thepassport ?

31') 3t'<1~I'<1 41'<1Y)c!~I~d-ql (fq"~fu;r

If yes, please give the details about passport.

Ct(9) ~ /~mr 6IdIOOU~I-q13Fj'1cf ~~?Whether applicant is havy Experince ofGun, Weaper Handling if yes give details

~/omft.Yes / No

~ /omft.Yes/ No

~/omft.Yes/ No

~/omft.Yes/ No

~) 3t~C;I'<IRI'(C)t:G ~1'<t1I~1 CPIUI("(II~

'\ Q ~~~Cfi1GT?

3t,(1~ 1'<1,oq~fu;r meR qmqr?

Are any criminal procedingsbefore a Court in india?

if yes, please give details

~/omft.Yes/ No

(f) 'Jft 3ffi ~ Cfffi'tT~, 11(>11CP)UI("(II~ ~ ~"ijJl6/I6/t1 fu8IT ~ ~. q ~ qctuJ&;)'ti~~~tffi;fRr ~ ~ +t@--<.IIt1meR~.

I herebyconfirm that i have not been convicted of any offence involiving moral turpitude and i shall submit mycharacter certificate from Police authority within one month.

:?) 'Jft3m'~ Cfffi'tT~ 'Jft~TRtfUP~ tffii 3Rff W8IT~8fCI)~ q)J1iCP'<U<.II'<13TQ1?I'~ 3T~TT CPlul("(IldT

~ ~ ~ 3t1\1fR11(>11~ ~.I declare that I am physically fit and not suffering from any disease or disability which would disqualify me f~r the

employment as Security Guard.

~) CR ~ ~ ~ q ~ ~ 3ffi'Jft~ Cfffi'tT.

I declare that information given above is correct and true.

~) ~ ~ +t1{'1CPicp~11(>11~CP~h11d) l'UdRl~ ~ 'Jft~ q)J1i ~. tffiT;r+16ool+tlcht1 ~ ~ /~/~ ~ mf ~~~ tffi'A ~ q ~ ~~T 11(>11~"1CPI'<CP'<1~tft{'1.I shall williingly work with the Employer, directed by the Board, Further I will obey the allottement / transfer /withdrawal/replacement etc. orders issued bythe Board,from time to time and such orders will be bindingon me.

\1IFTT :Place:

~:Date: 3t~C;I'<I-cft mft

Signature of the Applicant

~ d4~ldll-l-tlcftFOR OFFICE USE ONLY

~~RNOMINATION

C\) (~ "1~Pt~~A CP'<UII~lt"ll~ ~ cr~ ~ ~~GfI(f't"I~ «I~~ "1~r:1~~Acp'<IClrtft~~.) "* When the person nominating,has a familyand wishes to nominateone member therof.

~ m iN ~ ~SC51lcflt"l~ \i~R!.~("<.I1«Il4-at"ll.,tI~r:1~~A~ 3T1t.311f1tr~ ~ ~ ~ICI("<.II'tt~

~ ~ ~ ~, 'tPc!Qqr:1C1[e~, q ~ ~ ~~iR ~ 't<ftCPI'<U~I~131~CPI'<~ ~3T1t. '

I hereby nominate the person mentioned beow who is a member of my family to receive the amount on account of

gratuity, Providant Fund and other legal dues, that may stand to my credit, in the event of my death.

=?) (~.,i~r:1~~A CP'<UII~lt"llW. 311fUr~. «I~~ "1~r:1~~A CP'<I~~ ~ 3Rft;r.)

* ( When the person nominating has no family and wishes to nominate any person.)

~ W 'tt("<.ll~~~ ~ ~~("<.II«I~t"li ~ ~ ~lq("<.lI'<11W1T~ 6farR cp)ul~6T~ 't~Qqr:1qh;~, q ~ ~ ~~iR ~ 't<ftCPI,<u~I~1~ 'SIGR~ 3T1tI, havingnofamily,hereby nominatethe person mentionedbelowto receivethe amount that may stand to my creditin the event of my death. "

NameandAddressofNominee

Relationwith Age Married/ Unmarried

the personnominating

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~ «Iqcflt"ll ~ ~~ mr ~ ~ 3t~ft~~iR~ 3t'<1("<.11'<1,~"1icr tffiTq;mi.Name, Address and Legal relatinshipofthe person if any to whom the right of thenominee shall pass in the event of hispredecesing the person nominating.

, 1~r:14~A n ~

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R i~tIDated

~Month of

eNYear200

~at

r"\'f~A CP,<ulI~l~ ;net q ~Name & Signnature ofthe person nominating

3t)OO~UlIGFr m8flc;l,<i~ ~ q m31T

Names of two witnesses & Signatures

1)

2)

~) 1~r:1~~A CP'<UII~I~ t"l1r4I..ttl'< fcfxrr, 1~r:1~ffflr «IfchfI~1 ~ ill("<.Il'tt ~ ~ "141Pt~ffic:r CP'<UII~I ~

~ "1icrtffiT~ ~8IT ~(f(P ~ CPI~[t"I~ltIcpoo~J\.

* Tosubmitthenecesaryinformationof thenominationif therewill beanychangein the nominationFromafterthe, '

'marriage of death of,legal nominee.