Annex12mmm

8/19/2019 Annex12mmm

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Annexure-P1

Government of Haryana

Department of School Education

Sheet for “My Prole” section on MIS Portal.

# Please read the following instructions carefully before lling the service book form.

This document is prepared to help the employees make the information pertaining to

their personal prole readily available ith them hile uploading on the portal!

Use "AP#TA$ letters only.

Tick e.!." #here$er applica%le and strike&o' e.!. Male ( )emale" #hiche$er not applica%le.

)ields marked #ith * are mandatory.

Please ll correct information.

%ote& In case+ any of the furnished information is found to %e false or untrue or misleadin! or

misrepresentin!+ employee #ill %e held lia%le for it.



'asic Prole

Title *,

)ull -ame as in ser$ice %ook *,

Date of irth DD(M/-(0000" *,

1ender *, Male()emale(Trans!ender

23 di!it 4dhaar -um%er,

)ull -ame in 5indi*,

5a$e you e$er chan!ed your name 6 0es(-o,

If 0es+

Pre$ious -ame,

7eason for 8han!e in -ame,



Place of 'irth (etails

8ountry of %irth*,

State *,

District *,

Su%&district(Tehsil*,

irth 8ity(9illa!e(To#n *,

Marital Status*,



If Married+ Date of Marria!e*,

7efer to !uidelines at S.-o. 2 %elo#"

-ationality*,

Domicile of 5aryana*

0es(-o

7eli!ion*,

8ate!ory*,

8aste*,

8aste 8erticate -um%er,

if %elon!s to reser$ed cate!ory"



Photo!raph and Si!nature Details

Employee must ha$e a passport si:e colored

photo #ith #hite %ack!round scanned in .;p!

format #ith resolution of <==PPI. The le si:e

should not e>ceed ?==@. Scanned

photo!raph should %e handy on pendri$e or

computer for uploadin!.

Employee should put his(her si!natures #ith %lack ink pen on

a #hite paper and scan it #ith resolution of <==PPI in %lack

and #hite mode Do not use 1rey scale or colour" and sa$e it

in .;p! format. The le si:e should not e>ceed ?=@. Scanned

si!nature should %e handy on pendri$e or computer for

uploadin!.

Address (etails



)a* "orrespondence Address

8ountry*, I-DI4

State *,

District *,


8ity(9illa!e(To#n

*,

4ddress*, Aine 2

Aine 3,

Aine <,

Bard -um%er *,

Aandmark,







PI- *,

4ssem%ly 8onstituency *,

Parliamentary 8onstituency*,

Police Station*,

)b* Permanent Address

Is Permanent 4ddress same as 8orrespondence 4ddress 0es(-o If 0es+ no need to ll it up a!ain"

8ountry*,

State *,

District *,




8ity(9illa!e(To#n

*,

4ddress, Aine 2

Aine 3,

Aine <,

Bard -um%er *,

Aandmark,

PI- *,





Police Station*,

)c* Home Ton Address

Is 5ome To#n 4ddress same as Permanent 4ddress 0es(-o If 0es+ no need to ll it up a!ain"

8ountry*,

State *,

District *,




8ity(9illa!e(To#n

*,

4ddress*, Aine 2

Aine 3

Aine <

Bard -um%er *,

Aandmark,



PI- *,



Police Station*,

"ontact (etails

Aand Aine -um%er if any",

Primary Mo%ile -um%er*,



4lternate Mo%ile -um%er,

Primary Email ID*,

4lternate Email ID,

#dentity Prole

Permanent 4ccount -um%er P4-"*,

1P)(EP)(8P)(U8P)(P74- Select any one",

-o. ,

)or details+ refer !uidelines at S.-o. < %elo#"

Do you ha$e passport 0es(-o*,

If 0es+ Passport -um%er*,



Date of IssueDD(M/-(0000", *

Date of E>piryDD(M/-(0000", *

Passport issuin! authority*,

Place of issue,

Do you ha$e Dri$in! Aicense* 0es(-o



(Driving license Number " * , 7T/ 8ode,

Aicense -um%er,

Date of IssueDD(M/-(0000"*,

Date of E>piryDD(M/-(0000" *,

State from #hich license is issued*,

Aicense Type*,



Do you ha$e any disa%ilities* 0es(-o )ill up in any one or in multiple lines %elo#+ as the case may

%e"

9ision Impairment %lindness"*, C

Percenta!e of disa%ility*,

Do you ha$e the disa%ility certicate issued %y

district ci$il sur!eon6* 0es(-o,

9ision Impairment lo# $ision", C



district ci$il sur!eon6* 0es(-o,

5earin! Impairment *, C



district ci$il sur!eon6 *0es(-o,



5earin! Impairment, C



8ompetent 4uthority* 0es(-o,

Speech Impairment , C



8ompetent 4uthority * 0es(-o,

Aoco motor Impairment , C



8ompetent 4uthority* 0es(-o,

Do you ha$e any chronic diseases , 0es(-o )ill up in any one or in multiple lines %elo#+ as the case

may %e"

i"8hronic Disease -ame*,

8hronic Disease Description*,

Date of occurrence of 8hronic diseaseDD(M/-(0000"*,

Do you ha$e the certicate issued %y 4IIMS Includin! its %ranches in 5aryana" ( P1I 7ohtak ( P1I+

@hanpur @alan ( @alpana 8ha#la Medical 8olle!e+ @arnal ( P1I 8handi!arh(Duly 8onstituted Medicaloard* 0es(-o,



8hronic Disease -ame*,




@hanpur @alan ( @alpana 8ha#la Medical 8olle!e+ @arnal ( P1I 8handi!arh (Duly 8onstituted Medical

oard * 0es(-o,

ii"8hronic Disease -ame*,




@hanpur @alan ( @alpana 8ha#la Medical 8olle!e+ @arnal ( P1I 8handi!arh(Duly 8onstituted Medical

oard * 0es(-o,

iii"8hronic Disease -ame*,




@hanpur @alan ( @alpana 8ha#la Medical 8olle!e+ @arnal ( P1I 8handi!arh(Duly 8onstituted Medical

oard * 0es(-o,

+ital ,easurements

Identication Mark*,



lood 1roup,

5ei!ht in cms."*,

Bei!ht in @!s." *,

Date of Measurement DD(M/-(0000", *

ducational details )1.th

onards*

ducational /ualication & 1.th "lass

Brite the country from #hich you ha$e passed class 2= e>amination*,

State from #hich you ha$e passed class 2= e>amination*,

-ame of 8ertifyin! ody*,

-ame of Institution*,

Su%;ects Studied in 8lass 2=th

*,

Date of Passin!DD(M/-(0000"*,

(Evaluation Method rade !ystem or Marks system"



1rade System Details,

Marks System Details*,

8.1.P.4 /%tained,

Marks /%tained*,



Ma>imum 8.1.P.4

Ma>imum Marks*,

1rade*,

ducational /ualication & 10th "lass

Stream*,

Brite the country from #hich you ha$e passed class 23 e>amination* :

Select the state from #hich you ha$e passed class 23 e>amination*,


-ame of Institution*,

Su%;ects Studied in 8lass 23th

*,





1rade System Details*,


8.1.P.4 /%tained,

Marks /%tained*,

Ma>imum 8.1.P.4*,

Ma>imum Marks*,

1rade* ,

ducational /ualication & "erticate )Higher secondary Prep etc!

should also be taken here*

Brite the country from #hich you ha$e completed certicate* :

Select the state from #hich you ha$e completed certication*,

8ertifyin! ody typeoard(Uni$ersity(other"*,

-ame of 8ertifyin! ody,

8erticate -ame*,

Speciali:ation If any",



-ame of Institution ,





8.1.P.4 /%tained*,

Marks /%tained*,

Ma>imum 8.1.P.4,

Ma>imum Marks*,

1rade* ,

ducational /ualication & (iploma

Select the country from #hich you ha$e completed the diploma*,



Select the state from #hich you ha$e completed the diploma*,

8ertifyin! ody typeoard(Uni$ersity(other"*,


Diploma Ae$el4d$ance(asic(1eneral(Specic"*,

Diploma -ame*,


-ame of

Institution ,



1rade System Details,


8.1.P.4 /%tained*,

Marks /%tained*,



Ma>imum 8.1.P.4,

Ma>imum Marks*,

1rade* ,

ducational /ualication & (egree

Select the country from #hich you ha$e completed the de!ree *,



Select the state from #hich you ha$e completed the de!ree*,

Uni$ersity -ame*,

De!ree Ae$elachelor(Master(Doctor" *,

De!ree -ame *,


-ame of Institution *,


E$aluation Method 1rade System or Marks system





8.1.P.4 /%tained,

Marks /%tained*,

Ma>imum 8.1.P.4,

Ma>imum Marks*,

1rade *,

Select the country from #hich you ha$e completed the

de!ree *,


Uni$ersity -ame*,




De!ree -ame *,







8.1.P.4 /%tained,

Marks /%tained*,

Ma>imum 8.1.P.4,



Ma>imum Marks*,

1rade *,

Select the country from #hich you ha$e completed the

de!ree *,


Uni$ersity -ame*,


De!ree -ame *,









8.1.P.4 /%tained,

Marks /%tained*,

Ma>imum 8.1.P.4,

Ma>imum Marks*,

1rade *,



4ttach additional sheets if reDuired for more educational Dualications"

2amily Prole)3ther than spouse*

i" 7elation #ith Employeerother(Dau!hter(Son(Sister()ather(Mother(Mother&in&la#()ather&in&la#"*,

)amily Mem%ers )ull name as on 4adhaar 8ard* ,

4adhaar -um%er of family mem%er,

Marital Status of family mem%er*,


Mo%ile -um%er, Date of irth DD(M/-(0000"*,



Dependent on Employee6* 0es(-o,

4dd 8hronic Disease of family mem%er if any",

ii"7elation #ith Employeerother(Dau!hter(Son(Sister()ather(Mother(Mother&in&la#()ather&in&la#"*,


4adhaar -um%er of family mem%er to %e added,



Mo%ile -um%er,

Date of irth DD(M/-(0000"*,



iii"7elation #ith Employeerother(Dau!hter(Son(Sister()ather(Mother( Mother&in&la#()ather&in&

la#"*,







Mo%ile -um%er,




i$"7elation #ith Employeerother(Dau!hter(Son(Sister()ather(Mother( Mother&in&la#()ather&in&

la#"*,





Mo%ile -um%er,






$"7elation #ith Employeerother(Dau!hter(Son(Sister()ather(Mother( Mother&in&la#()ather&in&

la#"*,





Mo%ile -um%er,






4pouse (etails

Spouse Profession 1o$ernment Ser$ant+ 5aryana State 1o$ernment+ other State 1o$ernment

Employee+ Self&employed+ Pri$ate ;o%+ Pri$ate Uni$ersity+ oards and 8orporation+ 8entral

Uni$ersity+ Aa%ourer+ State Uni$ersity+ Unemployed+ State PSU+ )armer+ 8entral 1o$ernment+

Military Personnel+ Para&military Personnel+ 8entral PSU"*,

-ame of Department of 5aryana State 1o$ernment*,

Enter 4adhaar -um%er of Spouse,

)ull name as on 4adhaar 8ard*,



Employee 8ode*if #orkin! in same department",

Mo%ile -um%er,


4dd 8hronic Disease of spouse if any",

4alary 'ank Account (etails

e&Salary 8ode,

4ccount 5older -ame as on Pass%ook ( 8heue %ook*,

4ccount -um%er *,

4ccount Type 8urrent(Sa$in!"*,



I)S8 -um%er,

ank -ame,

ranch -ame,

4ccount Status 4cti$e(Inacti$e"*,

molument (etails

Select the Pay and *, I ( II ( III ( I9

1rade Pay*,

Entry Ae$el Pay,

Dearness Pay,



Special Pay,

5ouse 7ent 4llo#ance,

Total*,

Date from #hich you are dra#in! this 1rade Pay *,

Aard (etails

4#ard TypeState Teacher(-ational Teacher( -ational I8T(/ther"*,

4#ard -ame*,

4#ard Date*,

/rder -um%er*,

Guidelines5 instruction to ll up format&

To ll up marital status in %asic prole or family prole+ choose any one of the follo#in!,



Married(Di$orced(Bido#ed(Deserted(Separated( -e$er Married

)or landmark+ please indicate name of any reno#ned oFce+ %uildin!+ historical place+ etc.e.!. rail#ay station+ airport+ %us stand+ colle!e+ uni$ersity+ etc.

1P)&1eneral Pro$ident fund+ EP)&Employee pro$ident fund+ 8P)&8entral pro$ident fund+

U8P)&Unreco!ni:ed pro$ident fund+ P74-&Permanent retirement account num%er.

Annex12mmm

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