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A PPLICATIO N FO R ISSUE O F NO O BJEC TIO N C ERTIFICATE

FO R O BTA INING INDIA N PA SSPO RT


Nam e ofapplicant
Designati
onwith nam e ofOffice
3. Perm anentaddress

4. Payandscaleofpay

(a) DateofBirth
5. Date ofcommencementofcontinuous
service underGovernment
Place proposed to be visi
t
Purpose ofvisit

8. I
fitjsforseeking employment,whether
a decl
aration to the effectthathe will

eitherresignthisjoborwilltake prior
permission abroad has been attached
9. Exped ed peri
od ofabsence from duty

10. Address ofthe place ofvisitifavailable

11. How theexpenditureforjotlrneyandstayabroad :


12. Mode ofdisbursementofIeave salary

13. W hetherany disciplinarycase is


pending againstthe applicant
14. W hetheranyIiability is outstanding
againstthe applicant

15. W hetherapplicantis underany


contractualobligation bonded ornon
bohded with Governm entis so detai
led
lSolemnlyaffirm thatthe information given are correct
Signature ofthe appli
cant
1,.............-....-.......................................-...................................01fprfpt)jt(1(,1)11,rtrthll,t1hslI
-ll()lltlllrlr)rit)rr)llrryllislpl()r1frl)rrltkl(,
Governmentbefore I
eaving India to abroad.
.

Signature ofthe applicant.

PR O FO R M A REPO RT
(Tobefilled fn by theHeadofOff/ce)

W hetherany discipl
inal proceedings
are pending orcontemplated against
in indi
vidual

2. W hetherany Vigilance case is pending


orcontem pl
ated against him

3. W hetherthere are groundsto believe


thattheappli
cantcouldfigure adversel
y
onthe securi
tyrecordsoftheGovt.

Certi
fiedthattheinformationgivenaboveandthatgiven bytheapplicantSl.No.1to 15areverisedandfoundcorrect.
His application is recommended.

Signature:
Name:

Designation ofthe Officer:

Station:
Date:

DECG RATIO N TO ACCO M PANY THE APPLICATIO N F0 R


O BTAINING NO O BJECTIO N CERTIFICATE T TRAVEL
A BRO A D

Ido hereby declarethatIwillnotenjoy thestayabroadbeyondtheperiodof


leaveshown in my application

2. 1do hereby declare that Iwillnotindulge in m y any work ofpropoganda


whichw illbedeterm entaltotheinterestofnationality.

3. 1dohereby declarethatonly suchjob whichwillnoteffectmy statusasa


(P0st) Of
K eralaGovernm entwillbetnken undertheforeign em ploym ent
.

4. 1do hereby declarethatIw illabidebytherulesand conditionsasperG. 0.(P)

No.274/70Tin.dated,24-9-1970& G.0.(P)No.65/76/Fin.dated,25-2-1976.
Ido hereby declarethat1haveno bonded obligation to sel'
vetheD epartm ent
.

6. 1dohereby declarethatnovigilenceordisciplinary action againstm e

I dp hereby declare that l have not taken any leave for the sam e purpose
previously.

Signature
CountersignatureoftheHead ofOftk e

A N N EX U R E B
AlICentralG overnm entem ployees,State G overnm entem ployees,Em ployees of
Statutory Bodies and Public SectorUndeA kings and theirdependentfam ily
m em bers are required to produce an Identity Cedificate
(Strikeoutprotionnotapplicable)
(To begivenin Duplicateon OriginalStationary)

()fi:11,tthr)lrltlrll Ittrl1)plxhrltt,r'l4)1()54th(,()fttll
-ti(()fflce11(b(1rtliii;)............-......................................................

Ii1/18rtj18(1()r)llrlCl()r!tflhrthilh/rl(,rllL)thrti;)()f1581ri/t;rtlt....................-..-.,.....................................................
andhis/heridentityiscertified.ThisMinistry/Depadment/Organisationhasnoobjectiontohis/her
acquiring IndianPasspod.The undersigned isdulyauthorisedtosi
gnthisIdentityCerti
ficate.Ihave read

the provisionsofSection 6(2)ofthe PassportsAct,1967and certifythatthese are notattracted


in case ofthis applicant. 1recom m end issue ofan Indian Passportto him /her.ltis cedified thatthis

organizationis a central/State Government/PublicSector/undedaking/Statutorybody.TheIdentity

Ref.No & Date:

Applicant's
photo to be
adested by
certifying
authority

Nam e and Designation,Address &

A N N EXU RE C

INTIM ATIO N BY A N EM PLOYEE TO H I5 EM PLO YER O F H IS

INTqNTION TO APPW FO R A PASSPO RT


(ForAIICentralGovernmentemployees,StateGovernmentemployees,EmployeesofStatutoryBodiesand
PublicSectorUndelakingswhoarenotproducingaNoObjectionCerl/#cale)
(on Off/c/alStationa)

m y intention to apply fora passpod.

Signature& Seal.
The Head ofOffice
(i
n acknowledgementofthe
receiptofthesai
di
ntimation)

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