SCHEDULE III FORM I

(See Rule 24 - A)

APPLICATION FOR ‘ IDENTITY CERTIFICATE’ FOR APPLYING FOR GRANT/RENEWAL OF PASSPORT /AND ‘NO OBJECTION CERTIFICATE TO

NDERTAKE FOREIGN TRIP

(To be filled by the applicant)

1. Name, designation, office address & scale of pay (if selection grade, or special grade indicate respective ordinary grade scale of pay)

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2. Date of retirement :

3. Name of countries proposed to visit and duration (need not be filled up to obtain passport to seek employment abroad)

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4. Purpose of visit :

5. Source of funds to meet the cost of the proposed foreign travel

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6. State whether any criminal prosecution is contemplated or pending against you and whether your presence as witness would be needed in any criminal case under investigation or trial.

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CERTIFICATE

I undertake that I will uphold the honour and dignity of our Nation and will not indulge in any act prejudicial to the integrity and sovereignty of our country during my travel and stay abroad.

SIGNATURE OF THE APPLICANT

/counter sign /by head of the Institution

(TO BE FILLED BY THE HEAD OF THE DEPARTMENT)

7. Are the particulars furnished by the applicant correct as per information available with the department?

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8. Whether the presence of the applicant outside India, may or likely to prejudice the friendly relations of India with any foreign country.

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9. Whether the applicant at any time during the period of five years immediately preceding the date of his application, been convicted by a court in India for any offence involving mortal turpitude and sentenced in respect thereof to imprisonment for not less than two years?

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10. Whether any proceedings in respect of an offence alleged to have been committed by the applicant are pending before a criminal court in India.

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11. Whether any warrant or summons for the appearance or warrant for the arrest of applicant has been issued by a court under any law for the time being in force or whether an order prohibiting the departure from India of the applicant has been made by any such court.

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12. Whether the applicant has been repatriated and has not reimbursed the expenditure incurred in connection with such Repatriation.

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13. Whether any Government dues are pending recovery,. If so., the details thereof.

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14. Whether any disciplinary action is pending under Rule 17(b) of the Tamil Nadu Civil Services (Discipline & Appeal) Rules.

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15. Whether a certificate has been obtained from Special Branch CID (security) that the applicant does not figure adversely on the security records of the Government.

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16. Whether any corruption charges or vigilance enquiry is pending against the applicant.

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17. Is there any contractual obligation to be discharged by the applicant (applicable in case of travel for employment only)

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18. Recommendation of the Head of the Department.

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SIGNATURE OF THE HEAD OF THE DEPARTMENT /counter sign /by head of the Institution

ANNEXURE – I

PROFORMA PARTICULARS TO BE FURNISHED BY MEDICAL OFFICER WHILE APPLYING FOR NO OBJECTION CERTIFICATE / LEAVE OUT OF INDIA.

1. Name and Designation :

2. Whether he / she had obtained passport :on any earlier occasion

3. Purpose of visit abroad :

4. Countries proposed to be visited :

5. Whether the proposed visit abroad :is her first visit out of India. If not give particulars of earlier visit and purpose of

6. Proposed date of departure and period of : Visit

7. Whether visit will be undertaken at : his own cost

8. Whether he/ she has executed a bond prescribed:for the purpose (If he is applying for leave)

The particulars furnished the above or true to the best of my knowledge and belief and that I have not given any false information purposefully or suppressed any information.

SIGNATURE OF THE APPLICANT.

/counter sign /by head of the Institution

CHECK LISTPARTICULARS TO BE FURNISHED TO GO ABROAD ON SHORT VISIT ON

OWN EXPENSES.

NOTE: Written application of the Medical Officer / applicant to be submitted at least two months’ prior to the visit (in duplicate) unless otherwise it is on emergency and due to extra ordinary situation which should be vouched by the forwarding authority.

1.Application of the Medical Officer / applicant : requesting permission to Leave Out of India indicating the following:-

a) the country to which the visit is made :

b) reason for the visit : c) the period of absence specifying the dates for which leave is required :

d) whether valid passport is on hand with the applicant or not (Give passport Number) :

e) the proposal for issue of No Objection Certificate (NOC) to go abroad should reach this office two months’ in advance from the Date of proposed journey :

f) whether the medical officer is having private practice and if so the income derived from private practice should also be shown by the medical Officer in the income-tax statement for the particular year in which the proposed journey to be performed by him. :

g) source from which the expenditure for the proposed visit met by the medical officer : h) certificate to the effect that the proposed visit by the medical officer is the first / second visit during the calendar year :

2.Annexure I and II duly signed by the Head of Institution (induplicate) :

a) whether applicant is a Self Drawing Officer :

3.Leave Eligibility Report by the Dean / Head of Institution :

(NOTE: In case of Self Drawing Officers it may be obtained by the O/o the Director of Medical Education from Accountant General’s Office)

4.Service details is in the prescribed format (in duplicate) copy enclosed attested by the Dean :

5.Certificate by the Head of Institution that no disciplinary case is pending against the medical officer / applicant. :

6.Certificate by the Head of Institution that no Govt. money is due from the medical officer / applicant. :

7.Certificate by the Head of Institution that applicant have no subsisting contractual obligation with the Government :

8.Attestation form in duplicate duly filled in. :

9.Declaration by the applicant that no case is pending against him / her if any court of law, with the attestation of the signature by the Head of Institution :

10.Whether Service Register of the applicant enclosed with the proposal for permission for leave out of India :

11.Whether passport copy duly attested by the Gazetted Officer enclosed for applying for Renewal of Passport and leave out of India :

Assistant Office Superintendent Administrative Officer Dean

NOTE: THE APPLICATION WITH THE ENCLOSURES SHOULD BE NUMBERED SERIALLY THE NUMBER OF THE PAGE SHOULD BE NOTED AGAINST EACH ITEM (PARTICULAR / ENCLOSURE / CERTIFICATE ETC.) IN THE CHECK LIST. THE SIGNATURE OF THE APPLICANT SECTION SUPERINTENDENT AND THE JUNIOR ADMINISTRATIVE OFFICER / ADMINISTRATIVE OFFICER AND THE DEAN MUST BE OBTAINED AT THE END OF THE CHECK LIST.

PROFORMA

SERVICE PARTICULARS FOR ISSUE OF NO OBJECTION CERTIFICATE AND CLEARANCE BY VIGILANCE DEPARTMENT.

1. Name and designation of the Officer :

2. Father’s Name :

3. Date of birth :

4. Date of enlisting in Govt. Service :

5. Post held and places served during the :5 Years

6. Whether he / she is facing any enquiry : on the basis of the Directorate of Vigilanceand Anti Corruption report

7. Date of Retirement :

8. Date of going abroad :

DEAN / HEAD OF THE INSTITUTION

ATTESTATION FORM

1. Name in full & Designation :

2. Father’s Name :

3. Present Address :

4. Home Address :

5. Date and place of birth :

6. Education qualification showing places of education with year in School, since 15th year of age.

Name of School with full Address

Date of Entering Date of Leaving Examination Passed

Address where the candidate has resided for more than one year during the proceeding five years.From To

(1) (2) (3)

8. Particulars of previous employment if any held:

Full address of Designation of Last pay Period ReasonsOffice firm or post held or drawn From To forInstitution description of resignation

SIGNATURE OF THE APPLICANT.

/counter sign /by head of the Institution

DECLARATION

I, ___________________________________________________________ hereby

declare that there is no case pending against me in the Court of Law or any Vigilance

enquiry is being pending / contemplated / executed and I have no contractual obligation to

be fulfilled.

SIGNATURE OF THE APPLICANT

/counter sign /by head of the Institution

ANNEXURE – II

PARTICULARS TO BE FURNISHED BY THE HEAD OF THE DEPARTMENT

1. Name of the Applicant & Designation :

2. Whether the request of the Medical Officer : “No Objection Certificate” for obtainingpassport and for Leave out of India and orfound to be bonafied.

3. Whether any disciplinary action of :Vigilance Enquiry is pending or contemplatedAgainst the Medical Officer and whetherThere are any grounds to believe that theMedical Officer could figure adversely inThe Security Records of the Government

4. Whether grant of No Objection Certificate :to Medical Officer to obtain passport isrecommended

5. Whether the Medical Officer has any :subsisting contractual obligation to fulfill the Government

6. Whether request of Medical Officer :for Leave out of India is recommended andif so the period for which leave is to be sanctioned and nature of leave

7. If Leave out of India is recommendedwhether the bond executed by the Medical Officer is in order and whether it : Has been accepted by Head of the Department

Signature of the applicant Signature of the Head of Department

/counter sign / by head of the Institution

B.UNDERTAKING TO BE GIVEN BY APPLICANT

During my visit abroad, I shall not take up any appointment or undergo any training or

study programme abroad without the prior approval of the Government.

The Government will not be liable for any expenditure, including travel expenditure, etc.

in connection with the visit abroad.

I will not tender resignation of my appointment under the Government, while

abroad, I am aware that the Government not accept my resignation if tendered which I am

on leave abroad.

I shall not canvass or seak any business abroad.

Bearing unforeseen circumstances, I will not stay abroad beyond the period for which I

am granted leave out of India.

The passport that will be obtained on the basis of the No Objection Certificates that will

be issued to me on the basis of the undertakings) will be utilized for any subsequent visit

abroad without the prior permission of the Government.

I have executed a bond prescribed for the purpose of grant of leave out of India and I

shall abide by the condition of the bond.

I shall proceed abroad only after the leave Out of India is sanctioned to me by the

Government and Only after obtaining proper relief.

SIGNATURE OF APPLICANT. /counter sign /by head of the Institution

CHECK SLIP

AS PERSCRIBED BY THE GOVERNMENT

Granting of no objection certificate to leave abroad

1. Whether Service Book of the Medical Officer is enclosed :

2. Whether Xerox copy of passport is enclosed :

3. Whether copy of latest income tax return is enclosed :

4. From the time of joining in Government service how manytimes has the application gone abroad :

5. Private Visits Dates Expenditurebeyond places of visits From To :

Official Visits Dates : beyond places of visits From To

6. Whether necessary entries have been made in the : Service Register

7. Current visit-Expenditure met by whom :

8. Correlate with the income Tax Statement :

9. Proof of purchase of tickets through their source : --

Head of Institution. Director of Medical Education.

APPLICATION FORM FOR OBTAINING NO OBJECTION CERTIFICATE

1. Name of the application, his rank and unit which he/she is attached

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2. Name of the countries proposed to be visited :

3. Duration of stay :

4. Purpose of Visit :

5. Address of relatives friends, if any with whom the applicant proposed to stay while abroad.

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6. The probable expenditure for the journey to these foreign countries and how he will meet it. If the expenditure for such journey is proposed to be met by other a consent letter to that effect from the person concerned.

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7. Whether he has already visited any foreign countries and if so, particulars thereof

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8. The Month and year of the proposed visit :

9. Length of Service of the person concerned with the date of appointment

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10. Amount of credit of the subscribers GPF :

11. Applicant's assets furnished to Government :

12 Applicant is an income-tax payee, if so, any due to Government

CERTIFICATECertified that I will not stay in the foreign countries, I will return within the period

specified.

Signature of the applicant.

/counter sign /by head of the Institution

C E R T I F I C A T E

1. This is to certify that ________________________________________ he/she

has no disciplinary case is pending/ contemplated against him.

1. 2. This is to certify that ________________________________________he/she

has no Government money is due to be recovered from him.

Head of Institution

FORM II

IDENTITY CERTIFICATE AND NO OBJECTION CERTIFICATE TO APPLY FOR GRANT/ RENEWAL OF PASSPORT

(To be given in Duplicate)(See Rule 24-A)

Under rule 24-A of the Tamil Nadu Government Servants Conduct Rules, 1973, it

is Certified that Thiru/Tmt/Selvi Son / wife /daughter of Thiru

who is a temporary / permanent employee of this from and is at

present holding the post of Thiru/Tmt/Selvi who is

also an Indian national, is / are a dependent family members of Thiru/Tmt and

his/her identity is certified. This Department has no objection to his / her acquiring /

renewal of Indian Passport, Subject to the following conditions, namely :-

i) that the individual should not take up any appointment or undergo any training other than the one specified, if any or study programme during his/her stay abroad without prior approval of the Government/Head of the Department.

ii) that the Government / Head of the Department will not be made liable for any expenditure including travel expenditure etc., in connection with his/her trip abroad.

iii) that he/she should not tender resignation of the post held by him/her under this Government while abroad and his/her resignation of appointment will not be accepted on any account.

iv) that he/she should not canvas or seek any business while abroad.

v) that before proceeding abroad, he/she should apply to the Government/ Head of the Department for the sanction of leave to which he/she is eligible and get it sanctioned for the entire period of his /her absence.

vi) that he/she shall not use the passport obtained on the basis of the “Identity Certificate” for any subsequent trip abroad for any purpose without the prior sanction of the competent authority and

vii) that the “Identity Certificate” will be valid only for a period of six months from the date of issue.

The undersigned is authorized to sign this “Identity Certificate No Objection Certificate” I have read the provisions of sub-section (2) of section 6 of the passports Act, 1967 and certify that these are not attracted in the case of this applicant. I recommended issue of an Indian Passport to him/her, it is certified that, this Department is a State Government Department. The identity card Number of , Pan Card No. is …

Reference No. and Date Name , Designation and Address, telephone No.

Applicant’s photo to be attested by the certifying authority