f%® kht£l Kj‹ik¡ fšé mYtyç‹ brašKiw Miz

g.bt.v©: 001/m2/2019, ehŸ: .03.2019

bghUŸ gŸë¡ fšé¤ Jiw – MÁça®fŸ k‰W« gâahs®fŸ
bgëehL bršy mDk fl΢ӣL bgWjš / òJ¥Ã¤jš -
rh®ò.

gh®it 1.btëehL bršy mDk nfhç bgw¥g£l fU¤JU¡fŸ

2. jäœehL gŸë¡ fšé Ïa¡Feç‹ brašKiwfŸ e.f.v©:
67023/M®2/Ï1/2012, ehŸ: 31.08.2012.
-----
f%® kht£l gŸëfëš ÏUªJ btëehL bršy mDk nfhç bgw¥gL«
fU¤JU¡fŸ KGik Ï‹¿Í«, cça Mtz§fŸ k‰W« rh‹WfŸ Ïiz¡f¥glhkY«
bgw¥gLtjhš TLjš égu§fŸ nfhç¥ bgwΫ fU¤JU¡fis Ïa¡Fe® mt®fS¡F
gçªJiu¤ÂlΫ fhyjhkj« V‰gL»‹wJ.
vdnt btëehL bršy mDk nfhç bgw¥gL« é©z¥g§fŸ rh®ªJ V‰fdnt
gh®it 2-Ïš fhQ« jäœehL gŸë¡ fšé Ïa¡Fe® mt®fë‹ brašKiwfŸ efš
gŸëfS¡F mD¥g¥g£LŸsJ ÏU¥ÃD« KGikahd toéš fU¤JU rk®Ã¡F«
bghU£L fU¤Jéš Ïiz¡f¥glnt©oa Mtz§fŸ, rh‹WfŸ k‰W« khÂç
got§fŸ ϤJl‹ Ïiz¤J mD¥gyh»wJ.
MÁça®fŸ k‰W« gâahs®fŸ btëehL bršy mDk nfhç é©z¥Ã¡F«
bghGJ Ïiz¥Ãš f©LŸs cça got§fŸ k‰W« rh‹WfSl‹ fU¤JU¡fis
_‹W (3) efšfëš Ï›tYtyf« _ykhf gŸë¡ fšé Ïa¡Fe® mt®fS¡F mD¥Ã
btëehL bršy mDk bgw¥gl nt©L«.
nkY« fU¤JUéid _‹W khj§fS¡F K‹dnu gŸë¡ fšé Ïa¡Fe®
mt®fS¡F mD¥g¤j¡f tifæš fU¤JUéid jah® brŒJ mD¥g¥g¥glnt©L«
vdΫ, btëehL bršy gŸë¡ fšé Ïa¡Fe® mt®fS¡F fU¤JUéid mD¥Ã
mDk bg‰w Ëng btëehL br‹W tunt©L« vdΫ m¿ÎW¤j¥gL»wh®fŸ.
btëehL br‹W tªj Ë Kj‹ik¡ fšé mYtyç‹ mDk bg‰w
Ëdnu gâæš nru mDk¡f¥gl nt©L« vdΫ m¿ÎW¤j¥gL»wh®fŸ.
nkY« Jiwæ¡F cça Kiwæš jftš bjçé¡fhknyh mšyJ mDkÂ
bgwhkš btëehL br‹W tªjhnyh r«gªj¥g£lt® ÛJ Jiw rh®ªj fL« elto¡if
nk‰bfhŸs¥gL« v‹W« bjçé¡fyh»wJ.
mid¤J¥ gŸë¤ jiyik MÁça®fS«, mid¤J MÁça®fŸ k‰W«
gâahs®fS¡F m¿Îiuæid R‰W¡F é£L ifbah¥g« bg‰W nfh¥Ãš
guhkç¡f¥gl nt©L« vdΫ nf£L¡ bfhŸs¥gL»wh®fŸ.

Kj‹ik¡ fšé mYty®,

f%®.
Ïiz¥ò : khÂç¥ got§fŸ k‰W« rh‹WfŸ.
bgWe® : jiyikMÁça®fŸ, muR/efuit/cjébgW« ca®/nkšãiy¥gŸëfŸ.
efš : mid¤J ÃçÎfS¡F.
 btëehL br‹Wtu k‰W« éL¥ò mDk¡fhd got§fŸ k‰W« rh‹WfŸ

fl΢ӣL bgw jiyik MÁça® nkbyh¥g¤Jl‹ Ïiz¤J mD¥g¥gl nt©oa

got§fŸ k‰W« Ïiz¥òfŸ étu«.

1. jiyik MÁçauJ Kf¥ò foj« k‰W« gçªJiu

2. MÁçaç‹ bjëthd k‰W« KGikahd é©z¥g«
3. Application 1 – 18 colum SCHEDULE –III
4. Identification Certificate – 3 copies FORM –II
5. ANNEXURE – B - – 3 copies òif¥gl« x£l¥glš nt©L« - jiyik
MÁça® ifbah¥g« Ï‹¿
6. Service Certificate – 3 copies
7. No Disciplinary action and No Vigilance case Pending.
8. Local Police Station Certificate (m‹ikæš bgw¥g£lJ)
9. Source of fund (Letter from sponser or Bank statement Copy)
10. Surety Certificate – 2 teacher’s Bond
11. Purpose of Visit & Country Name.
12. gaz¡ fhy« vªj njÂæèUªJ vªj nj tiu
13. éL¥ò jFÂ rh‹W
14. fl΢ Ó£o‹ efš mid¤J g¡f§fŸ.
15. fl΢ Ó£L¥ bgw Jiw mDk tH§»a efš mšyJ fl΢ӣL bgw
é©z¥Ã¤J jftš bjçé¡f¥g£l efš
 SCHEDULE –III
FORM-1
(See Rule 24-A)
Application for "identify Certificate" for applying for Grant of Passport / and
"No Objection Certificate" to undertake foreign Trip
(To be filled by the applicant)

1. Name and Designation office address and

scale of pay (if selection grade or special
grade indicate respective ordinary grade
scale of Pay)

Scale of Pay and Basic Pay and Grade Pay

2. Date of Retirement

3. Name of Countries proposed to visit, and

duration (need not be filled to obtain passport
to seek employment aboard)

4. Purpose of visit

5. Source of funds to meet the cost of the

Proposed foreign travel

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

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 aboard.

Residential Address Signature of the Applicant.

 (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
8. Whether the presence of the applicant outside
India, may or likely to prejudice the friendly
relations of India with any foreign country?
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 moral
turpitude and sentenced in respected thereof to
imprisonment for not less than two years?
10. Whether any proceeding in respect of an offence
alleged to have been committed by the applicant
is pending before a criminal court in India.
11. Whether any warrant or summons for the
appearance of 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?
12. Whether the applicant has been repatriated and
has not reimbursed the expenditure incurred in
connection with such repatriation.
13. Whether any Government dues are pending
recovery, if so, the details there of?
14. Whether any disciplinary action is pending under
rule 17 (b) of the Tamil Nadu civil Services
(Discipline and appeal) Rules
15. Whether a certificate has been obtained from
special Branch C.I.D (Security) that the applicant
does not figure adversely on the security records
of the Government.
16. Whether any corruption charges or Vigilance
enquiry is pending against the applicant.
17. Is there any contractual obligation to be
discharged by the applicant (applicable in case
of travel for employment only
18. Recommendation of the Head of the
Department.

SIGNATURE OF THE HEAD

OF THE DEPARTMENT
 FORM –II
IDENTIFY CERTIFICATE TO APPLY FOR GRANT / RENEWAL OF PASSPORT
(To be given in Duplicate)
(See Rule 24-A)

Certified that Thiru/Tmt/Selvi…………………….………………………….

Son/Wife/Daughter of Thiru………………………………………..is a temporaty / Parmanent
employee of this …………………………(Office address from………… (Date) and is at
present holding the post…………………………
Thiru/Tmt/Selvi………………………………….. is a dependent family member of
Thiru/Tmt………………………………….… And his/her identify is certified. This
Department has no objection to his / her acquiring Indian Passport subject to the following
conditions namely:-

1. That the individual should not take up and appointment or under go any training
other than the one specified, if any or study programme during his / her stay
aboard without approval of the Government / Head of the Department.
2. That the Government / Head of the Department will not be made liable for any
expenditure including traveling expenditure etc., in connection with his / her trip
abroad.
3. 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.
4. That he / she should not canvass or seek any business while abroad.
5. 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.
6. That he / she shall not 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.
7. That the “Identify Certificate” will be valid only for a period of six months from the
date of issue.
The undersigned is authorized to sign this “No Objection Certificate”. I have read
the provision of Sub-section (2) of the Passports Act, 1967 and certify that these
are not attracted in the case of this applicat. I are commend issue of an Indian
Passport to him / her. It is certified that this Department is a State Government
Department. The identify Card Number of Thiru / Tmt (employee)
…………………………………… is

Applicant photo to be attested by the certifying authority.

 GOVERNMENT OF TAMIL NADU
ANNEXURE – B

STATE GOVERNMENT EMPLOYEES AND THEIR DEPENDENT FAMILY MEMBERS ARE

REQUIRED TO PRODUCE A IDENTITY CERTIFICATE

(To be given Duplicate on original Stationery)

Certified that SHRI/SHRIMSTHI/KUM…………………….....................

Son / Wife of Shri. ……………………………………………………………..
Of is a temporary / permanent employee of this (Office address)
…………………………………………………………………………………………..…………….
. from …………(Date)……………………………………. and is at present holding post of
Shri/Smt/Miss/Mst. …………………………………………………is / are a dependent family
member(s) of Shri / Smt ……………………………………. and his / her identify is certified.
This Ministry / Department / Organization has no objection to his / her acquiring Indian
Passport. The undersigned is duly authorized to sign this identify certificate. I have read
the provisions of Section 6(2) of the Passport Act, 1967 and certify that these are not
attracted in case of this applicant. I recommend issue of an Indian Passport to him / her.
It is certified that this organization is a Central / State Government / Public Sector /
Undertaking / Statutory body. The Identify Card Number of Shri/Smt.(Employee)
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, is ----------------------------------
(GPF/CPS No)

Name,Designation,Address&Tel.No.

Ref.No.
Date.

Applicant photo to be
attested by certifying
authority
 Form III

NO OBJECTION CERTIFICATE

TO UNDERTAKE FOREIGN TRIP

(See rule 24 – A)

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

Thiru/Tmt/Selvi. ___________________________________________ working as

____________________________ (specify designation) in the department of

___________________ ( specify the department) is permitted to visit ______________

(specify the country/countries) from ____________ to ________(specify the dates) to see

his son/daughter/other relatives/friend or as a tourist or on pilgrimage or to attend a

training- seminar/workshop- conference, (strike out which is not applicable) subject to the

following conditions:-

(i) He / she should not take up any appointment or undergo any training /
seminar/workshop/conference other than the one specified, during his / her
stay abroad without prior permission 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) He/she should not tender resignation of the post held by him / her under the
Government while abroad and his – her resignation of the appointment if
tendered while abroad will not be accepted on any account:

(iv) He/she should not canvass or seek any business while abroad:

(v) This ‘No Objection Certificate” is valid for a period of six months from the
date of issue and it is issued only in connection with the purpose indicated
above and should not be used of any other purpose”
 Ïiz¥ò-2
1. muR Cêa® / MÁçaç‹ bga® :

2. gjé :

3. gâòçÍ« Kftç :

4. ãuªju Kftç :

5. Å£L Kftç :

6. Ãwªj nj :

7. gâæš nr®ªj ehŸ :

8. gâtu‹Kiw brŒj ehŸ :

9. XŒÎ bgW« nj :

10. filÁ Iªjh©Lfëš gâòçªj :

gŸëfŸ k‰W« gâah‰¿a fhy§fŸ

é©z¥gjhuç‹ ifbah¥g«.

nk‰fh© MÁçaç‹ gâ¥gÂnt£o‹go rçgh®¡f¥g£lJ vd¢

rh‹wë¡f¥gL»wJ.

jiyikahÁça®.

nkbyh¥gäl¥gL»wJ.

Kj‹ik¡ fšé mYty®,

 rh‹W

_________________ kht£l«, _________________ t£l«, ____________ muR

nkšãiy¥ gŸëæš ________________ MÁçauhf¥ gâah‰W«

ÂU/ÂUkÂ._______________________ v‹gh® btëehL bršy Ñœ¡f©lthW

rh‹wë¡f¥gL»wJ.

1. m‹dh® ÛJ jäœehL Foik¥gâ (xG§F Kiw k‰W« nkš KiwpL)

éÂfë‹go xG§F elto¡if VJ« ãYitæš Ïšiy vd¢

rh‹wë¡f¥gL»wJ.

2. m‹dh® ÛJ éê¥ò¥ gâ Miza¤Âš nfh¥ò VJ« ãYitæšiy vd¢

rh‹wë¡f¥gL»wJ.

3. m‹dh® muR¡nfh, muR rhuh ãWtd¤Â‰nfh brY¤j nt©oa ãYit VJ«

Ïšiy v‹W«, m‹dh® rh®ªj jâ¡if¤jil VJ« ãYitæš Ïšiy v‹W«

rh‹wë¡f¥gL»wJ.

4. nk‰f©l rh‹WfŸ Ï›tYyf nfh¥òfŸ k‰W« gÂntLfë‹ mo¥gilæš

rçgh®¤J rh‹wë¡f¥gL»‹wJ.

jiyik MÁça® ifbah¥g«.

 rh‹W

_________________ kht£l«, _________________ t£l«, ____________ muR

nkšãiy¥ gŸëæš ___________ ghl____________ MÁçauhf¥ gâah‰W«

ÂU/ÂUkÂ._______________________ v‹ghuJ <£oa éL¥ò¡ fz¡»š ehsJ njÂæš

______________ eh£fS« brhªj mYtè‹ngçyhd <£lh éL¥Ãš _______________

eh£fS« ÏU¥Ãš cŸsbjd¢ rh‹wë¡f¥gL»wJ.

jiyik MÁça® ifbah¥g«

 khÂç got« (Ãizahs®)
mD¥òe®

bgWe®
gŸë¡ fšé Ïa¡Fe®
gŸë¡ fšé Ïa¡ff«
fšÿç¢rhiy
br‹id

tê: 1. jiyik MÁça®

2. Kj‹ik¡ fšé mYty®
mŒah
bghUŸ: ÂU .................................................. v‹gh® btëehL bršy Ãiz¢ rh‹W
tH§Fjš rh®ò

................................ kht£l« ...................................... nkš/ ca® ãiy¥gŸëæš

................................. ghl .........................................MÁçauhf gâah‰W«..................................... ÂU/ÂUkÂ
................................... M»a eh‹, btëehL bršy cŸs ÂU/ÂUk ............................................,
........................ MÁça® .................................... nkš/ca® ãiy¥ gŸë ...................................... ,
..............................kht£l« v‹gh® btëehL br‹W tªJ Ûs gâna‰F« tiuæš eh‹
btëehL bršy kh£nl‹ v‹W« m‹dh® vd¡F e‹F bjçªjt® v‹W« vd¡F
bjçªjtiuæš m‹dh® ÛJ tH¡FfŸ, òfh®fŸ VJäšiy v‹gij gâÎl‹
bjçé¤J¡ bfhŸ»nw‹.

j§fŸ c©ikÍŸs
Ïl«
njÂ
Ãizahs® ifbah¥g«
 gâ¢rh‹W

................................ kht£l« ...................................... nkš/ ca® ãiy¥gŸëæš .................................

ghl .........................................MÁçauhf gâah‰W«..................................... ÂU/ÂUk ...................................

v‹ghuJ bkh¤j¥ gâ¡fhy« ...................... M©LfŸ MF«. m‹dh® Ï¥gŸëæš

.......................................... Kjš ................................ Mf gâah‰¿ tU»‹wh®.. m‹dh® XŒÎ bgW«

ehŸ ..............................MF«. m‹dhuJ mo¥gil CÂa« .k‰W« CÂa ãiy...........................

(CÂa ãiy) vdΫ Ï›tYtyf gÂntLfŸ k‰W« nfh¥òfë‹ mo¥gilæš rçgh®¤J

rh‹wë¡f¥gL»‹wJ

jiyik MÁça® ifbah¥g«