List of Forms & Formats

Sl Form & Formats Page No

1. Application for Passport 2
2. Declaration format for Passport 3
3. Application for Issue of Service Certificate 4
4. Option for Sodexho Pass Food Voucher. 5
5. Self Audit Report format 6
6. Application for Bank Loan 7
7. Application for Transfer to other units of SAIL on Compassionate grounds 8
8. Application for Payment of Gratuity (For Nominee) 9
9. Application for Payment of Gratuity (For Ex-Employee) 10
10. Enquiry Report In Cases of Injury on Duty (For Executives) 11
11. Enquiry Report In Cases of Injury on Duty (For Township Area) 12
12. Form of Agreement for Advance for the Purchase of Motor Vehicle 13-14
13. Rules for Grant of Advance for the Purchase of Motor Car / Motor Cycle 15-16
14. Application for issue of Photo ID card or Vehicle Pass (In Joining on Appointment/Transfer) 17
15. Application form for Incentive Scheme For Acquiring Professional Qualification 18
16. Declaration for Medical Re-imbursement 19
17. Final settlement of Provident Fund (For the member) 20
18. Final settlement of Provident Fund (For the Nominee or Other claimant(s)) 21
19. Request for Forwarding Applications for Employment Outside RSP 22
20. Quarter Option Application Performa 23
21. Application for Re-imbursement of House Maintenance Expenses 24
22. Application for Retention of Facility (ies) on Transfer 25-26
23. Srujani Form 27-28
24. Declaration for Income Tax exemption under perquisites (PPC: 976) 29-30
25. Declaration for Private Foreign Visit 31

Main Page
Doc No : IMS/PR/Pers/Comm-10.05, Rev.4
Date 13-11-2014

Annexure - I

APPLICATION FOR ISSUE OF IDENTITY CERTIFICATE FOR OBTAINING PASSPORT

To
The Unit Personnel Executive
(Through proper channel)

1 Name of the Applicant

2 Father’s/Husband’s name
1
3 Personal Number

4 Designation & Scale Code

5 Department / Section

6 Purpose for obtaining Passport

7 Particulars of dependant in respect of Name Relationship

whom Identity Certificate is sought

8 I have read the provisions of Section-6(2) of the Passport Act,1967 and declare that the
same are not attracted in my case / the case of my dependent in respect of whom the
Identity Certificate is sought. A self declaration to this effect submitted by me / my
dependent is enclosed herewith along with Two Passport size photographs of me/my
dependent and a photocopy of my gate pass/Identity Card.
(Strike out the part not applicable)

Date ________________ Signature of Applicant

FOR OFFICE USE ONLY
The applicant has fulfilled the Identity Certificate as requested may be issued.
requirements for issue of Identity
Certificate.

Signature :
Name : Signature of HOD
Designation : (with Seal)

(Unit Personnel Executive) Date :

Date :

Doc No : IMS/PR/Pers/Comm-10.05,
Rev.4 Date :13/11/2014
Annexure - II

SELF-DECLARATION

I,_____________________________________________,Pl.No._______________Son/Daughter/Wife of

_________________, residing at ________________________, Date of Birth _____________ do hereby

state as follows:

1. That I am an applicant for issue of pass port under The Pass Port Act, 1967.
2. That the names of my parents and spouse are as follows:
(i) Father :
(ii) Mother :
(iii) Wife/Husband :
3. That I am continuously resident at the above mentioned address from ________________.

2
4. That I am citizen of India by birth/descent/registration/naturalization and that I have neither
acquired the citizenship of another country nor have surrendered or been terminated/deprived
of my citizenship of India.
5. That I have not, at any time during the period of five years immediately preceding the date of this
self-declaration, been convicted by any court in India for any offence involving moral turpitude
and sentenced in respect thereof to imprisonment for more than two years.
6. That no proceedings in respect of any criminal offence alleged to have been committed by me are
pending before any criminal courts in India.
7. That no warrant or summons for my appearance, and no warrant for my arrest, has been issued
by a court under any law for the time being in force, and that my departure from India has not
been prohibited by order of any such courts.
8. That I have never been repatriated from abroad back to India at the expense of Government of
India/I was repatriated from abroad back to India at the expense of Government of India, but
reimbursed expenditure incurred in connection with such repatriation.
9. That I will not engage in activities prejudicial to the sovereignty and integrity of India.
10. That my departure from India will not be detrimental to the security of India.
11. That my presence outside India will not prejudice the friendly relations of India with any foreign
country.
12. That I am submitting this self-declaration to produce the same before concerned authority,
SAIL, Rourkela Steel Plant, Rourkela for the purpose of issuance of Identity Certificate in
connection with my application for issue of an Indian Passport.
DECLARATION

I, _________________________, Son/Daughter/Wife of ________________________________Age______,

Year________ resident of ______________________________District__________________,hereby declare that

the information given above and in the enclosed documents is true to the best of my knowledge and
belief and nothing has been concealed therein. I am well aware of the fact that if the information
given by me is proved false/ not true, I will have to face the punishment as per the Service rules of
the company/law of the land. Also, all the benefits availed by me shall be summarily withdrawn.

Place: Rourkela

Date: Applicant

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Main Page
IMS/PR/Pers/Comm-10.02-Rev.1
Date: 23.12. 2011

APPLICATION FOR ISSUE OF SERVICE CERTIFICATE

TO,
The Unit Personnel Executive
(Through Proper Channel)

1 Name ( in full and in capital letters)

2 Personal Number
3 Designation & Scale Code
4 Department /Section
5 Date of joining RSP
6 Father’s Name

7 Permanent Address

8 Present Address

9 Purpose of the Certificate To register Name of Dependant in Employment Exchange/ To obtain

Residential/Domicile Certificate

10 Particulars of Dependant

a) Name

b) Relationship with applicant

c) Date of Birth

d) Medical Treatment Book No

11 My dependant mentioned above is residing with me at Rourkela for the past ------------------------ years. The above
information furnished by me are true to the best of my knowledge.

Date:------------------------------ Signature of the applicant----------------------------------------------------

12 Particulars at SLNos 1 to 9 have been verified from the records and found to be correct.

Date :----------------------------------------- Signature of the HOD with seal

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To

The DGM (Personnel-OD),

SAIL, Rourkela Steel Plant,
Rourkela - 769011.

Sub: Option for Sodexho Pass Food Voucher.

Ref: Circular No. PL/OD/SPSI/06 dated 17.04.2007.

Sir,

I, Shri/Mrs. ______________________________ Pl.No. __________,

Designation______________________ , Department _____________________ wish to receive my

monthly dues towards lunch/meal coupon through Sodexho Pass Food Vouchers.

I further acknowledge and declare that having exercised this option I shall have no claim for money

on the aforesaid score paid to me every month as per my entitlement and reflected in my Pay-slip.

Place : Rourkela Signature) __________________________

Date : Name :

Mobile No:

E-Mail id:

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(For internal use in Personnel Department only)

SELF AUDIT REPORT

STANDARD : ISO 9001:2008 QMS
Self-Audit No.: __ Date: _______ UNIT Audited :
Name & Designation of Auditor :
Name & Designation of Auditee :

Corrective &
Preventive
SL. Process Audited Observation
Action to be taken
(CAPA)
1.
2.
3.
4.

5.

Observations regarding Monitoring & Measurement of Services :

Observations regarding customer’s requirements/Customer’s complaints / EAR :

Compliance of _____ Self Audit : ---

GENERAL POINTS :

(Signature of Auditee) ` (Signature of Auditor)

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ANNEXURE-I

STEEL AUTHORITY OF INDIA LIMITED

ROURKELA STEEL PLANT

ROURKELA
To
The _______________________
(Unit Personnel Executive)
_______________________

(Through Proper Channel)

Sir,
I want to avail loan from _______________________Bank / Financial Institution. For this purpose,
a Certificate may please be issued in favour of me, to enable me to avail the loan from the Bank / Financial
Institution. My Permanent, Present address are given below:

Present Address: Permanent Address:

AT: AT:
PO.: PO :
PS.: PS.:
DIST. DIST.:

Signature :

Name :

PL. No. :

Designation:

Rourkela Deptt. :
Date:

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 PL-OD MainPage
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PL-OD
APPLICATION FOR TRANSFER TO OTHER UNITS OF SAIL ON COMPASSIONATE GROUNDS

( To be submitted through Proper Channel )

To
Dy. General Manager (PL-OD)
Rourkela Steel Plant
Rourkela – 769011.

Request for Transfer to :- Unit ___________________, City :___________

Please √ ( Unilateral Transfer or Mutual Transfer )

( If on Mutual, Name of Partner :____________________________________________ )
Please enclose consent letter of the partner.
(A) DETAILS OF EMPLOYEE :
1 Name ( S/ Shri )
2 Personal Number
3 SAIL Pl.No.
4 Designation
5 Department Working Department : Posted Since :
6 Date of Birth
Course Yr. of Passing % Marks Institute / University

7 Qualification

Date Unit Joined as (Designation)

Date of joining SAIL / UNIT
8
Date of joining RSP Date Unit Joined as (Designation)
9 ( If joined on transfer )
10 Date of last promotion Date : Grade :
From To Duration Programme Place
11 Training Abroad, if any

(B)
REASON FOR TRANSFER Put Documents
Please Elaborate
( Please tick which is applicable) Tick Enclosed

1 Spouse posted at different location.

Medical reasons/ ill health of self,

2
spouse, children or parents

3 Tragic incidences in the family Yes / No

4 Education of self and children

5 Old age of parents, etc.

DATE : _____________ SIGNATURE OF THE EMPLOYEE

Mobile No. ___________________

FORWARDED BY HOD Remarks :

( Signature & Seal )

Thro: GM Concerned
( Signature & Seal )

ED Concerned
( Signature & Seal )

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PL-OD
ANNEXURE - VI

R S P / FA APPLICATION FOR PAYMENT OF GRATUITY O&M

& CAO / (To be filled by Ex-employee) 115155
FS (T)
NAME (IN BLOCK LETTERS) Personal No. Deptt. where last worked Date & Cause
& DESIGNATION of Release -

Put ‘X’ Non Executive Executive

in the
App. box
MODE OF Postal Money A/c Payee A/c payee cheque to my account at my own
PAYMENT Order at my cheque sent risk : (A/c No., Name of Bank, its full Branch
( ‘X’- cross the cost in case the through post at address etc., as given below) :
app. Box only) amount is less my risk :
than Rs.500/-
By Applicant

Address in Block letters where

remittance and intimation will be
sent

I declare that the particulars mentioned above are true and correct to the best of my knowledge and
belief.
Date:
Place: Signature / Left thumb impression of the applicant
Certified that the above declaration is signed / thumb impressed in my presence by
Sri / Smt. ________________________________________.

Date: Signature of the authorised

Office Seal person ( X )
( X ) Following are authorised persons :
[ 1] Magistrate [ 2] Gazetted Officer [ 3] President of Village Panchayat [4] Chairman / Secretary
/ Member of Municipal / Local for District Board [5] M.P. or M.L.A. [6] Head of Deptt./ Office
Date of Date of eligibility Date of Total Service Period of leave Total qualifying
For use in Department [ To be filled from

joining (in case of release rendered :- without pay :- service

HSL / apprentices and from HSL / [ Difference of
SAIL :- Graduate Engg.) :- SAIL :- previous two
columns ] :-
Y M D Y M D
service records ]

Last drawn Pay + DA [in case of Executive, as per Amount of Gratuity

SAIL Gratuity Rules] Rs. P

Certified that the above information is correct on the basis of service records of Sri /
Smt.____________ __________________________. Further, it is certified that he / she has rendered
good, efficient and faithful service to the Company.

Date: Signature of Head of Dept./ Office

Office Seal
Passed for payment of Rs. _____________________ [ Rupees _________________________
_____________________________________ ]
For use in

Office only
Accounts

Assistant Accountant Accounts Officer

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ENQUIRY REPORT IN CASES OF INJURY ON DUTY (For Executives)

Name

Personal Number

Designation & Scale code

Department/Section

Local Address of the employee as per

official records

Date and time of accident Date: ___________________ Time: ________________

Place of Accident

Mode of Travel

Normal duty hours

Time the case was reported at IGH/OHSC

Nature of injury

Cause of accident as investigated

Conclusions drawn:

Signature of Enquiry Officer(OD) Signature of Enquiry Officer(Safety)

( with seal ) ( with seal )

Signature of Enquiry Officer(Department)

( with seal )

The Special disability leave from _________ to ___________ is approved.

Signature of the HOD (with seal)

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PL-OD
ANNEXURE – IV

ENQUIRY REPORT
(For cases of injury / illness while on duty)

Particulars of the Employees :

Name : _________________________________, Pl.No._____________ Age:_____ yrs, Sex:_______

Designation: __________________________ Scale code:________ Department _________________

Area of work :

Particulars relation to occurrence of injury / illness :

Date of occurrence : ________________________ Time of occurrence __________ shift __________

Exact Place of occurrence :

Name (s) of witnesses witness interrogated :

Brief account of Investigation :

(To be filled in injury cases)

Was the injured person using Personal Protective Equipment : YES / NO

Was any unsafe practice followed : YES / NO
(If yes, give a brief account) :

Does the case come under the purview of IOW : YES / NO

Signature of Enquiry Committee.

Deptt. Representative: Unit Personnel Executive:

Name : Name:
Designation : Designation:

Head of Department

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ANNEXURE -II
Of PPC No.387

FORM OF AGREEMENT FOR ADVANCE FOR THE

PURCHASE OF MOTOR VEHICLE
[To be executed on non-judicial stamp paper of Rs. 50/- (Rupees Fifty only) ]

This agreement made this _______day of the month _________of the year ___________between
Sri/Smt./Miss __________________________________ son/daughter of ________________________in
employment in Steel Authority of India Limited, RSP,as _________________ hereinafter called the “Employee” of
the one part which will include all their heirs, assigns and executors, and the Steel Authority of India Ltd., RSP,
hereinafter called the “Company” of the other part.

Whereas the Employee has applied and had been granted an advance of
Rs.______________________(Rupees ______________________________________) for the purchase of a Motor
Car/Motor Cycle/Scooter/ Scootrette/ Moped in accordance with the rules of the company presently in force or to be
subsequently amended and whereas the said amount of Rs.____________________ has been received by the
Employee, the Employee hereby agrees to conform and abide by the following terms and conditions: -

1) That the payment of the above said amount will be made by the monthly instalments of
Rs.__________ out of the monthly pay and remuneration of the Employee and the Company will
be entitled to deduct the same out of his salary.

2) That the said amount of Rs._________ shall carry interest at _______ per annum.

3) The Employee shall purchase Motor Car/Motor Cycle/Scooter/ Scootrette / Moped for which
advance has been sanctioned to him by the Company within 30 days from drawal of advance
from the Company, and shall submit complete set of documents as required under the rules
within 30 days of the purchase of the vehicle; and in the event of failure to comply with the
above or any other provisions of rules, the Company shall be entitled to the refund of the entire
advance in full along with the interest calculated at the rate of _______per cent per annum
within 60 days from the date of the drawal of the advance from the Company.

4) That in the event of not purchasing the Motor Car/Motor Cycle /Scooter/ Scootrette/Moped
and the failure to refund the advance with interest to the Company within 60 days of the date
of drawal of the money, the Company shall be entitled to take such disciplinary action as it
may deem fit against the Employee.

5) The Employee shall hold such advance in trust for the Company and shall be liable for breach
of trust in case the Employee spends or utilises the money for any other purpose and shall be
liable to the Company for such breach of trust, not withstanding any practice to the contrary
and the Company shall be entitled to take such disciplinary action as it may think fit.

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6) That immediately after the purchase of Motor vehicle, the Employee shall get it insured against
full loss of fire, theft or accident with a recognised Insurance Company and will also write a
letter in the prescribed form to the Insurance Company as required by the Rules of the
Company.

7) That the Employee shall also execute a Hypothecation Agreement with respect to the motor
vehicle purchased by the Employee on the prescribed form as required by the Rules of the
Company.

8) That if the Employee leaves the service of the Company or his services are terminated for any
reason whatsoever before complete payment and realisation of the whole amount advanced
and interest thereon, the Company will be entitled to realise the amount due from the
Employee and from the Final Settlement dues of the Employee.

9) That the Employee undertakes to conform strictly to the terms of this Agreement and further
agrees that in case of violation of any of the terms of aforesaid, the Company will be entitled to
realise the entire amount together with interest due from the Employee.

In witness whereon the Employee put his hand this ___________day of the month
___________of the year aforesaid at __________

Witness Signature of Employee________

Date Name of Employee___________

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ANNEXURE-IV
of PPC No.387
HYPOTHECATION AGREEMENT

RULES FOR GRANT OF ADVANCE FOR THE PURCHASE OF

MOTOR CAR / MOTOR CYCLE (INCLUDING SCOOTER/
SCOOTRETTE/ MOPED)

[To be executed on non-judicial stamp paper of Rs.50/- (Rupees Fifty only)]

This agreement made this……………day of the month………………….of the year………………between Shri

/ Smt./Miss …………………………….. son/ daughter of ………………………………… in employment in Steel
Authority of India Limited, as …………………….. hereinafter called the “Employee” of one part, which expression
shall include all the heirs, executors and assigns of the employee, and the Steel Authority of India Limited, Rourkela
Steel Plant, Rourkela (hereinafter called the Company of the other part).

Whereas the Employee had applied and had been granted an advance of Rs……………
(Rupees……………………………..) for the purchase of a Motor Car/Motor Cycle/Scooter/Scootrette/Moped in
accordance with the Rules of the purchase of Motor Car/Motor Cycle/Scooter/Scootrette/Moped of the Company
presently in force or to be subsequently amended from time to time and whereas one of the conditions of the
Agreement is that the Employee shall hypothecate the said motor vehicle to the Company as Security for the amount
advanced by the Company, and whereas the Employee has purchased with, or partly with, the amount so
advanced the Motor Car/Motor Cycle/ Scooter/ Scootrette/ Moped the particulars of which are set out in the schedule.

Now this Hypothecation Agreement witnesseth that in pursuance of the said Agreement, and for the
consideration aforesaid, the Employee doth hereby agree to pay to the company the sum of Rs…………aforesaid, or
the balance thereof amounting to Rs………….by equal instalments of Rs…………each month on the first day of the
month, with interest on the unpaid balance calculated at the rate specified in the Rules for grant of advance for the
purchase of a Motor Car/Motor Cycle/ Scooter/Scootrette/Moped of the Company and the Employee doth agree that
such instalments may be recovered by the Company by monthly deductions out of his salary in the manner provided
in the said Rules and in further pursuance of the agreement, the Employee doth hereby assigns and hypothecates
the said Motor Car/Motor Cycle/Scooter/Scootrette/Moped to the Company.

The Employee doth hereby declares that he has paid in full the purchase price of the said Motor Car/Motor
Cycle/Scooter/Scootrette/Moped to the Company and that the same is his exclusive property, and that he has not
pledged or pawned the said vehicle any where else, and shall not pledge or pawn it so long as any money remains
due to the Company and the Employee hereby agrees that if at any time, the Employee shall die, or leave the service
of the Company, or in any other manner become unfit or unable to pay to the Company of it the Employee may sell or
pledge or in any other manner part with the possession of the said vehicle, or if the said vehicle is attached in the
execution of any decree against the Employee, the entire

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unpaid balance together with all interest shall become payable, and the Company shall be entitled to recover the
same from the Employee and from his heirs and assigns, and it is further agreed that in the event of the happening of
any of the above said circumstances the Company shall be entitled to take possession of the vehicle and sell the said
vehicle either by public auction or private contract, and if the sale proceeds fall short of the dues to the Company to
realise the balance from the Employee’s terminal dues. And the Employee, further agrees that so long as the entire
amount of the Company is not paid up, he shall not in any way cause any damage or suffer or permit the vehicle to
be damaged in anyway, so long as this agreement is not completely discharged, and in the event of any accident or
damage to the Motor Vehicle during the continuance of these presents, shall cause same to be repaired and made
good forthwith at his own expenses.

In witness thereof the said Employee…………………has hereinto…………………….set his hand

this…………day of the month…………………….of the year above mentioned at…………………

Witness Signature of Employee________________________

Date Name of Employee___________________________

THE SCHEDULE

Description of the motor vehicle with cost,

Marks etc.

Signature of Head of Deptt./ Office

(With Seal)

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17
ANNEXURE-II Main Page

(PPC No.932)
STEEL AUTHORITY OF INDIA LIMITED
ROURKELA STEEL PLANT
ROURKELA

APPLICATION FORM
(Ref.Rule 8.0)

INCENTIVE SCHEME FOR ACQUIRING PROFESSIONAL QUALIFICATION

To,
The Executive Director (P&A)
Steel Authority of India Limited
Rourkela Steel Plant,
Rourkela.
/ THROUGH PROPER CHANNEL /
Name :

Personal Number :

Designation :

Department/Section :

Grade & Present Pay :

Examination Passed :

Date of Passing the Examination :

Incentive, if any, drawn earlier on :

account of additional qualifications.

Documentary proof of examination :

passed is enclosed.

Date __________________ Signature of the applicant

_________________________________________________________________________
FOR OFFICE USE ONLY

Verified the above particulars and recommended.

Date: Signature of Head of the Deptt.

with seal.

Unit Personnel Executive

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ANNEXURE-I
PL-OD (TO PPC No. 961)

DECLARATION FOR MEDICAL REIMBURSEMENT

I, _______________________________________________________PL. No__________
Dept.___________________________________ certify that I have purchased the following
medicines for self / dependent _________________________________________ as prescribed
by the doctor of IGH/ HC on_____________________________ which may kindly be
reimbursed to me through salary. These medicines are not included under nutrition, vitamins,
toiletries or disinfectants.
Sl. No. Name of Medicines Quantity Price
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
Total Rs.

(Total claim for rupees in words: ------------------------------------------------------)

In case of referral cases: I enclose herewith a photocopy of the discharge certificate of the
hospital to which I/ my dependant family members was referred on
________________________. (The referral number is ____________________________)
I hereby enclose _____________ number of bills with prescription (in original) in support
of my claim.

Signature of the employee

Applicable in case the claim of medical reimbursement is Date:
in excess of Rs.2000/-)

Vetted the claim

Signature of the Concerned Treating Doctor with Seal

Signature of Head of Deptt. with Seal

F&A (IGH)
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PL-OD
ANNEXURE - IV

RSP Final Settlement of Provident Fund Form No.

FA & CAO ( To be filled by the Member ) 2165
( PF )
Name [in Block letters ] Designation Personal No. P.F. A/c No. Deptt. where
last worked

Last Drawn Date of release Date of joining Date of Total Service Whether
B/Pay + DA from SAIL SAIL joining P.F. Y. M. D. member of V.
P. F.

Reason for withdrawal [office order reference] Resignation / Removal / Dismissal / Med. Unfit /
Termination / Transfer / Superannuation / V.R.

Mode of payment ['X' - Postal Money Order at my A/c payee cheque A/c payee cheque sent to
cross the appropriate box cost [in case the amount is sent through post my account at my own
only] less than Rs.500/-] risk

Address in Block Letters where remittance and

intimation will be sent :

Address in Block Letters of the present employer

where balance is to be transferred :

Consent of the present employer to accept the transfer and Letter Reference is to be indicated and
the status of PF including the name of the beneficiary Letter to be attached

I declare that the particulars mentioned above are true and correct to the best of my knowledge and belief.

Place: Signature / Left hand thumb impression of the

Date: Applicant
Certified that the above declaration is signed / thumb impressed in my presence by
Sri / Smt. Employed at

Date:

Seal of Office Signature of the authorised person (*)

Certified that the above information is correct

Seal of Office Signature of Head of Dept./ Office

(*) Following are authorised persons:
1] Magistrate 2] Gazetted Officer 3] President of Village Panchayat
4] Chairman/Secretary / Member of Municipal / Local of District Board 5] M.P. or M.L.A. 6] Head of
Deptt./ Office 7] Contractor

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PL-OD ANNEXURE – V

RSP Final Settlement of Provident Fund Form No.

FA & CAO (PF) [To be filled by Nominee or Other Claimant(s)] 2165
Name [in Block Letters] Address - Age Relationship with the
deceased

Name, Designation of the Deptt./ Section Personal No. P.F. A/c No. Whether
deceased employee – where last worked & C.C. member of
V.P.F.

Last Drawn Date of Date of Family particulars of the deceased, if the claimant is other than
B.P. + D.A. death joining HSL / Nominee
SAIL Name Age Relationship with
deceased

Date of
joining P.F.

Mode of payment (‘X’ - Postal money order at my A/c payee cheque sent A/c payee cheque sent
Cross the appropriate cost (in case the amount is through Post at my own to my account at my
box only) less than Rs.500/-) risk own risk

Address in Block letters

where remittance and
intimation will be sent

I declare that the particulars mentioned above are true and correct to the best of my knowledge and belief.

Place: Signature / Left hand thumb

Date: impression of the Applicant
1. Certified that the above declaration is signed / thumb impressed in my presence by Sri / Smt.
_________________________________________________________________________.
2. Certified that the declaration regarding the death of Sri/Smt. ________________________
_________________________________ mentioned in the above declaration is correct.

Date: Signature of the authorized

Seal of Office person (*)

Certified that the above information is correct.

Seal of Office Signature of Head of Dept./Office

(*) Following are authorised persons:

1] Magistrate 2] Gazetted Officer 3] President of Village Panchayat 4] Chairman / Secretary / Member
of Municipal District 5] Concerned Deptt.’s Executive (only P.F. card holders).

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ANNEXURE-II

REQUEST FOR FORWARDING APPLICATIONS/ ISSUE OF NO OBJECTION CERTIFICATE FOR

EMPLOYMENT OUTSIDE RSP

To be filled in by the Applicant

1 Name
2 Personal Number
3 Designation & Scale Code
4 Department / Section
5. Details of Post applied for (Copy of advertisement and application enclosed)
Post Scale of Pay Organisation

6. Whether under bond, if yes date up to which bond is

valid
7. Whether sponsored for training abroad, if yes, details
of training
8. Whether applying through internet?

9.
Date:___________ Signature of applicant

FOR OFFICE USE ONLY

The above particulars have been verified and found to be correct.

Signature & Seal of HOD/Office

Forwarded to Unit Personnel Executive

The applicant fulfils the requirement of the advertisement. The application is complete/ incomplete and confirms /
does not confirm to Personnel Policy Circular No.1044 dated 25-05-2015. Forwarding of the application/ issue of
NOC may / may not be approved.

Signature
Name and Designation of Unit Personnel Executive

Competent Authority

Unit Personnel Executive

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OPTION APPLICATION PROFORMA

To,
Manager(TS) Allotment
SAIL, RSP, Rourkela.

Ref: ___________________________________________ Dated :___________________

Class of Quarters Applied for ____________________________________

1. Name ______________________________________ 2. Pl.No. ________________

2. Designation: _______________________ 4. Department: ____________________

5. Code Nos. of Qrs Applied for Sl.No.

I do hereby declare that :-

1. I have not been allotted the same of higher class of quarters either on option during the
last two years or on seniority allotment after 01.05.1995.
2. I have gone through the terms and conditions of the circular and House Allotment Rules
1995 and shall abide by it.
3. Neither I nor my spouse has drawn any installment of House Building Advance granted
by the Company for constructing / acquiring a house or enlarging the existing house
within the Rourkela Municipality or Rourkela Industrial Township area and neither I nor
my spouse or any of my dependants have constructed or acquired a house or enlarged
the existing house within Rourkela Municipality area of Rourkela Industrial Township
area on the land allotted by the company or otherwise made available through the aegis
of the company.
4. The information furnished above are correct.

Rourkela Signature of the applicant

Date:

Certified that the information furnished above are correct as per records available in his service
book.

Date: Head of Deptt./Office(seal)

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ANNEXURE – I
(To PPC No.911)

STEEL AUTHORITY OF INDIA LIMITED

ROURKELA STEEL PLANT
ROURKELA

REIMBURSEMENT OF HOUSE MAINTENANCE EXPENSES

This is certify that I am in occupation of Quarters No. _______________ type of Quarters _____________,
Sector _____________ in SAIL, Rourkela Steel Plant, Rourkela. I have spent Rs. _____________ (Rupees
________________________________ only ) wholly, exclusively and necessarily towards small
maintenance jobs in my allotted quarters for the financial year __________________, which may be
reimbursed to me.

Signature :
Name :
Pl.No. :
Designation :
Department :

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ANNEXURE-I
(PPC NO. 1085 )

STEEL AUTHORITY OF INDIA LIMITED

ROURKELA STEEL PLANT
ROURKELA

Application for Retention of Facility (ies) on Transfer

(In Duplicate)

(THROUGH PROPER CHANNEL)

 
1. Full Name (in block letters)  
2. Personal Number  
3. Designation  
4. Department /Section  
5. Grade  
6. Date of joining  
7. Transferred Location (Pl. Mention Location)  
8. Facility (ies) on Retention and Period of Retention
9. Reason for Retention Education of dependent Children/ Employment of
Spouse/Medical cases of dependents/ Non-availability of
quarters as per entiltlement rules at new location
(Please tick the applicable choice)
10. Company Accommodation at previous Place of Company Leased/Company Owned/Self Leased/HRA
Posting & (Please tick the applicable choice)

Qtr no. and address of Company:

accommodation
11. Accommodation retained at previous Place of Yes/No
Posting
12. Period of retention 1 year(1st /2nd /3rd /4th / 5th year)
(Please tick the applicable choice)
13. Company Accommodation required at Yes / No
Transferred location
14. Guest House / Transit House/Hostel to be Yes / No
availed at transferred location
15. Telephone facility retained at previous place of Yes/No (Pl. tick in box)  
posting With STD / Without STD  
(Pl. indicate in box)
16. Period of retention 1 year(1st /2nd /3rd /4th / 5th year)
(Please tick the applicable choice)
17. Air Conditioner at previous place of posting Yes/No
18. Medical Facility of dependents at previous place Yes/No
of posting
 

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2. Particulars of Dependent Family Members:

  Name Relationship Age

(i)      
(ii)      
(iii)      
(iv)      
(v)
(vi)
3. Declaration by the employee
1. I have read and understood the Rules governing Retention of Facilities on Transfer.
2. I agree to abide by the provisions of the Rules.
3. I hereby declare that particulars of my dependents furnished by me are true and I have not concealed any
fact.
 
 
Date:
 
Signature of the Employee
 
 
To be used by Personnel Department
 
The number of dependent family members and age has been verified.
 
Ref.: Personnel Policy Circular No. 1085
 
Date:
 
 
Signature and Seal of Unit Personnel Executives
 
 
 
Signature of the Competent Authority (Head of Personnel)
 
Copy to: Employee concerned.
 

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