DEPARTMENT OF SCEOOL EDUCATION GOyI.

OF WESTBENGAL
SCEOOL DETAILS '
Teacherstrfi Itrfomation S)sten

l.
2

Nameofschml
DISEcode 9

PERSONAL DITAN,S

4.

Date

ofBftth:

t
Mr^.ft . (first)

6
SpouseName
:

Celrder fPut r' markl

tl T
F

8. 9.

Whederspouse is enployed

(p$,r' mark):

1colr.Aided ! [ n (fts/ma*onrypropriatebox):Hindu[TCt i"tiun[7euaarctlllut[lu*ri.flparsintodersl 10. Casle(Put /mark): ceneral f] f SC n 7 Sr ! 7 OnC !

Relision:
(pur

covr

L / covt. Underlaking n

yesn /NoE;

Ifyes, details dfemplolment (put r' mark on appropriate box): private 7 corr. sponsorea // / othe;E

rl. WhfierDifferedlyAbled

r'lllalk):'{es

ffYs, statedetaits (ilut /llarkotrappropriate box/boxes):

12 MoftaTongue: (Pu ftarkonappropdatebox):

n / Non
A+n / A

13.Heish:mn- fJ]inch
Bloodcmup(put

/ !.r n/ r{R n / pH n Bqs.ttr yp"gr^r,I/ninA,lWepurfl/S,hrf-l/Urdt io6eNn

m

14.

r5.pANNo.: fTT-T.l TTTTX

17 VoterID/EPICNo.
18.
: :

nark on appropriate box):

n/B+n/B-n7m+!7aa-[lo+n/o_n
16. unique rDNo.:

Identitrcation Mark

CONIACT DET{LS
19.

Presed Address :
House No.
:

Town/Mflage:

Posto6ce:
Dlstrict
20. Whetler prmaneit addrcss is same to

tlat ofpresnt

address? (put

r' mark)

tfnot, Permmed Addrcss

HouseNo.:

YesI / Non

Town/Vilage: Post0ffice:
District
21. Land TelNo. : 23.

22. MobileNo-:

EtrailID:

PROFESSIONAL DOTAILS
24. Dde .

ofioining{dsarvice)

25. D?6e ofjoidng 6e prEsrlrposr:

['signdion:

(ht /

narr( on apFopriare bcx):

HT/HMf

?.

/flcn iAI{I{n /er!

:

7r,m*ia"[ 7 cr"*n

lc..lE

EdEcational Qualification : (Pur ,,. mark on appropdare box) Under craduate Hotrs. craduate / pass cladua&

f]

n /

n /

Post Graduale

Ifnot u{dr craduate,

Ll

stare Subjct :

2& Profesiional Quatification: Forprimaryschool

sraft

mr!7 rrrrf]

O.ea,O.Elea[7 O6ersI

For secordary school

sraffs

Brn / B.Edn/ PGBrn

/ BPEdn/N,IEdE/ specialB.Edn/ othersn

Date
:

29- Appointment Ltter Number : 30. Approval

ofAppointme (issued by DyDSE^VBBSE) for secondary school staffs

Number:

Date:
Confirmation Date
:

MC Resolution No.

ll.

Status ofprevious ofemplolrnent,

ifatry

Name ofthe School

DTStr code

32. Qualification at the time

ofenty:
:

i3

Subsequent Qualification duly approved by the District Inspector of Schools (SE)

34. Date ofpossessing the professional qualificatiotr :

dulyfcognizedbyNatioml councilforTeacherEducafion? (Put.,/nl ftk): (dath cum retircment 36 Wtether opted under West Betrgal recogaized non-govemment educatioMl institutions employees benefit) scheme, 1981 : (Put,/ mark) : Yes Pensioa Famity Pension Scheme existing priorto 0l'04 19s1n; CPF with 37. optionBxercise lrnder @ut
35. Wtethertheprofessionalqualificationis

YsIAof]

I lNon

Pension with Graruity 3& lfopted

f-l

'znark):

Gatuitl;

uder Post l98l PensioF

:

Date ofrefund ofemployer's share of CPF to the Govt. Treasury Name ofTreasfuy
:

:1. methe,

*y Court Ciii ffiGin!@e" r'nark):Yesn / Non

in comection with his/h$ service is pendirg before the Ilon'ble Coud (Put

IfYes, CaseNo:

Year:

TfTfI
:

YYYY

Rlatd with

SALARY DETAILS
,10. Pay

in Pay Batrd

4l. Glade Pay :

42 Pay Band No

(as per ROPA-2009) :

:
:

43. Savings BankNam

.t4. SavinesBankBnrch Nam (with Code)

,5. SavrngsBalkAcrountNo. (SalaryAc.ountNo)

46 Ba*IFSC cod
:

HM s Si8naturcwi0'

date

Statr Si$ature with date

Instruction Sheet for frlling trp offorE

Tb b trlled up by school

lt8fs

(a) Atl

O) (c)
(d)

iej fict

(0

G)

the fields to be filled up in E4lish otrly in Block Ltters thefields. Please fitl up Please put one Character/LetterNumber in ore box. Please put conect DISE school code (l l digits) at field no "2"' (7) nart slouu be put in the appropriate box ftom anong th vanous options' For Sl. No. 6 & 7, iffather or spouse is dead' 'LT'to be Fefixed befor nam' For Sl. No. 42,43,44 & 45 provided infomation ofyou salarv accoud only'