NOTIFICATION FOR APPOINTMENT UNDER THE RAJIV GANDHI GRAMIN LPG - PDF

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NOTIFICATION FOR APPOINTMENT UNDER THE RAJIV GANDHI GRAMIN LPG - PDF Powered By Docstoc
					                            NOTIFICATION FOR APPOINTMENT UNDER THE RAJIV GANDHI GRAMIN LPG VITARAK YOJANA FOR ORISSA
1.  INDIAN OIL CORPORATION LTD (IOCL), BHARAT PETROLEUM CORPORATION LTD                                           brother(s) and unmarried sister(s). In case of divorcee, ‘Family Unit’ shall consist of individual   10. CORPUS FUND SCHEME - Financial Assistance to Candidates Selected for RGGLV
    (BPCL) and HINDUSTAN PETROLEUM CORPORATION LTD (HPCL) propose to appoint                                      concerned, unmarried son(s)/unmarried daughter(s) whose custody is given to him/her. In                  Locations Reserved Under SC/ST Category.
    RAJIV GANDHI GRAMIN LPG VITARAK YOJANA (RGGLV) under various categories at                                    case of widow/widower, ‘Family Unit’ shall consist of individual concerned, unmarried son(s)/                Candidate Selected for RGGLV locations reserved under SC/ST category will be provided a
    locations specified below from amongst the candidates belonging to different categories                       unmarried daughter(s).                                                                                       secured loan of Rs. One Lakh for construction of Godown/other facilities by the concerned
    mentioned herein in the State of Orissa:                                                                      (f)   have minimum total amount of Rs 2 lakhs put together from Saving accounts in Bank (as                  Oil Company. This amount will be recovered on per refill basis at the rate of 20% of distributor’s
Sl.    Oil Company      Name of RGGLV Location                  District       Category                                 on date of application), free and un-encumbered fixed deposits in scheduled banks,                     commission for 14.2 kg cylinders as per policy.
No.                     (Town/Village(s))                                                                               Kisan Vikas Patra, NSC, bonds, any other investment, etc in the name of self or family                 For RGGLV locations reserved under SC/ST category, the concerned Oil Company will provide
1      IOC                Simulia                                      Baleswar            CC                           members of the ‘Family Unit’ as defined above. (In case of RGGLV locations reserved                    adequate working capital loan for operation of the RGGLV at an interest rate of 11% per
2      IOC                Khaira                                       Baleswar             O                           under ‘SC/ST’ category, applicants with less than Rs 2 lakhs are also eligible to apply).              annum on reducing balance. Both, the working capital loan as well as interest will be recovered
                                                                                                                        For evaluation purpose, marks will be awarded to applicants of all categories based on                 in 100 equal monthly installments from 13th month of commissioning of the RGGLV.
3      IOC                Ambadoni                                     Baragarh            SC
                                                                                                                        the amount mentioned in the application.
4      IOC                Jharbandh                                    Baragarh             O                                                                                                                          11. SECURITY DEPOSIT
                                                                                                                  (g) own a suitable land (plot) of minimum 20 metre X 24 metre in dimension at the advertised
5      IOC                Gaisilat                                     Baragarh            CC                                                                                                                                  The selected candidate before being issued the appointment letter shall have to deposit
                                                                                                                      RGGLV location for construction of LPG cylinder Storage Godown.
                                                                                                                                                                                                                               interest free refundable security deposit of Rs. 2 lakhs with the concerned Oil Company. The
6      IOC                Tentulikhunti                                 Bolangir            O                     Own means having clear ownership title of the property in the name of applicant/family member                Concerned Oil Company will have the right to adjust any dues to it from this amount at the
7      IOC                Belpada                                       Bolangir            ST                    of the ‘Family Unit’ as defined in multiple dealership/distributorship norm. In case of ownership/           time of resignation/ termination. However, in case of termination of the RGGLV on account of
8      IOC                Khaparakhol                                   Bolangir            O                     co-ownership by family member, consent letter from the family member will be required.                       proven malpractice, the said security deposit shall be forfeited.
9      IOC                Turkela                                       Bolangir           CC                     Land for construction of Godown will be considered suitable, if it is freely accessible through      12. PERSONAL SUPERVISION
                                                                                                                  all weather motorable approach road (public road or private road of the applicant connecting
10     IOC                Dhamnagar                                     Bhadrak             O                                                                                                                                  A person selected for RGGLV should personally manage it. He/she will not be eligible for
                                                                                                                  to the public road) and should be plain, in one contiguous plot, free from live overhead power
11     IOC                Barkot                                       Deogarh              O                     transmission or telephone lines. Pipelines / Canals / Drainage / Nallahs should not be passing               taking up any other employment. If the selected person is already employed he/she will have
                                                                                                                                                                                                                               to resign from the employment & produce the letter of acceptance of resignation by the
12     IOC                Raimal                                       Deogarh             CC                     through the plot.
                                                                                                                                                                                                                               employer before the issuance of Letter of Appointment by the Oil Company.
13     IOC                Dharamshala                                    Jajpur             ST                    (h) be physically and mentally sound to be able to run the business
                                                                                                                                                                                                                       13. COMMISSIONING OF RGGLV
14     IOC                Laikera                                     Jharsuguda            O                     (i)   neither have been convicted nor charges been framed by any Court of Law for any
                                                                                                                        criminal offence involving moral turpitude/ economic offences.                                         Field verification will be carried out for the selected candidate and if information given in the
15     IOC                Champua                                      Keonjhar            CC                                                                                                                                  application by the candidate is found to be correct, Letter of Intent will be issued. Selected
16     IOC                Jhumpura                                     Keonjhar             O                     (j)   not be a signatory to distributorship/dealerships agreement, terminated on account of                  candidate who has been given the ‘Letter of Intent’ (LOI) would be required to fulfil the terms
                                                                                                                        proven cases of malpractice/adulteration of any Oil Company.                                           and conditions as contained therein, so as to commission the RGGLV within the stipulated
17     IOC                Telkoi                                       Keonjhar             SC
                                                                                                        4         SPECIFIC ELIGIBILITY CRITERIA FOR DIFFERENT CATEGORIES :                                                     time period. Before commissioning, Letter of Appointment will be given and RGGLV agreement
18     IOC                Koksora                                      Kalahandi            ST
                                                                                                                  a.    Open Category (O)                                                                                      shall be executed. The duration of the agreement will be initially for five years, renewable for
19     IOC                Golmunda                                     Kalahandi            O                                                                                                                                  every five years thereafter, subject to the satisfactory performance of the RGGLV.
20     IOC                Madanpur-Rampur (Madanpur)                   Kalahandi           CC                     Candidate fulfilling common eligibility criteria can apply under ‘Open’ category.
                                                                                                                                                                                                                       14. GENERAL
21     IOC                Lanjigarah                                   Kalahandi            O                     b.    Scheduled Caste/ Scheduled Tribe Category (SC/ST):
                                                                                                                                                                                                                               (a) The company reserves the right to cancel/withdraw/amend this advertisement or extend
22     IOC                Bangiriposi                                 Mayurbhanj            O                     The candidates belonging to castes/tribes recognised as Scheduled Castes/ Scheduled Tribes                       the due date at its sole discretion without assigning any reason.
                                                                                                                  (SC/ST) under the Constitution of India will be eligible.
23     IOC                Bahalada                                    Mayurbhanj           CC                                                                                                                                  (b) Application for RGGLV can be submitted on a plain paper hand written neatly or typed as
                                                                                                                  The candidates will be required to submit along with application a certificate issued by the                     per format given in the advertisement. After submission of application, no addition /
24     IOC                Komna                                        Nuapada              O
                                                                                                                  competent authority notified by the Government of India certifying that the candidate belongs                    deletion/ alteration will be permitted. Applicant should number all pages of the application
25     IOC                Rengali                                     Sambalpur             O                     to Scheduled Caste /Scheduled Tribe.                                                                             including affidavits attached therewith and sign on each page. All affidavits have to be
26     IOC                Gobindapur - Bamra                          Sambalpur             ST                    c.    Combined Category (CC)                                                                                     submitted in original along with the application.
27     IOC                Manesar                                     Sambalpur             O                     Applicants belonging to any of the following categories can apply for RGGLV under                            (c) Only those documents that are sought in the Application format should be submitted
28     IOC                Balisankar                                  Sundergarh           CC                     ‘Combined Category’.                                                                                             along with the application. Any additional document will not be considered.
29     IOC                Kutura                                      Sundergarh            O                     i) Defence Personnel Category (DP):                                                                          (d) Applications received after the cut-off date including postal delay, and those without
                                                                                                                                                                                                                                   accompanying valid documents including application processing fee or incomplete in
30     IOC                Lafripada                                   Sundergarh           SC                     Defence Personnel means personnel of armed forces (viz. Army, Navy, Airforce) and will                           any respect will not be considered. No correspondence will be entertained by respective
31     IOC                Himagiri                                    Sundergarh            O                     cover widows/dependents of those who died in war, war disabled/disabled on duty, widows/                         Oil Company in such cases.
32     IOC                Bishra                                      Sundergarh           CC                     dependent of those members of Armed Forces who died in harness due to attributable causes
                                                                                                                                                                                                                               (e) Except for locations advertised under ‘Open’ category, the eligibility certificate for the
                                                                                                                  and disabled in peace due to attributable causes.
33     IOC                Koida                                       Sundergarh            O                                                                                                                                      respective categories viz – ‘SC/ST’, and Combined Category (CC) consisting of Defence
                                                                                                                  Candidate applying under this Category should produce Eligibility Certificate issued from                        Personnel (DP), Paramilitary/Police/Government Personnel (PMP), Outstanding Sports
34     IOC                Lahunipada                                  Sundergarh            ST
                                                                                                                  Directorate General of Resettlement (DGR), Ministry of Defence, and Government of India                          Personnel (OSP), and Physically Handicapped (PH) has to be submitted.
35     IOC                Basta                                        Baleswar             O                     sponsoring the candidate for the RGGLV for which he/she has applied. Certificate of eligibility              (f)     If any statement made in the application or in the documents enclosed therewith or
36     IOC                Remuna                                       Baleswar             SC                    issued for one RGGLV is not valid for another RGGLV and therefore a candidate can be                                 subsequently submitted in pursuance of the application by the candidate at any stage is
37     IOC                Veden                                        Baragarh             O                     considered to be eligible only if he/she has been sponsored for the particular location with                         found to be incorrect or false, the candidature and application is liable to be rejected
                                                                                                                  reference to current advertisement                                                                                   without assigning any reason and in case the applicant has been appointed as a RGGLV,
38     IOC                Deogaon                                       Bolangir           CC
                                                                                                                  ii) Paramilitary/Police/Government Personnel Category (PMP):                                                         the same is liable to be terminated. In such cases the candidate/RGGLV shall have no
39     IOC                Puintola                                      Bolangir            O                                                                                                                                          claim whatsoever against the respective Oil Company.
                                                                                                                  The personnel of Paramilitary/Police including persons having served in BSF, CRPF, CISF,
40     IOC                Muribahal                                     Bolangir            ST                    ITBP, Railway Protection Force, Special Reserved Police, Special Armed Police, Coast Guards,                 (g) Applicants should provide only that information against various items of application, for
41     IOC                Teleibani                                    Deogarh              O                     Assam Rifles etc. as designated by Central Government and Police Forces of the States,                           which they are in possession of supporting documents in original as on the date of
42     IOC                Biramaharajpur sadar                          Sonepur            CC                     Customs and Central Excise Department, Narcotics Control Bureau, Enforcement Directorate,                        submission of application. Failure to present these documents in original at the time of
                                                                                                                  Economic Intelligence Bureau, Directorate General of Anti-Evasion and Directorate of Revenue                     verification will result in cancellation of selection due to submission of false/unsupported
43     IOC                Tarbha                                        Sonepur             O
                                                                                                                  Intelligence and those serving in different Departments of Central/State Governments who                         information.
44     IOC                Narla                                        Kalahandi            O                     are incapacitated or disabled while performing their duties will be eligible under this category.            (h) The envelope containing the application, duly filled in, should be superscribed as under
45     IOC                Dharmagarh sadar                             Kalahandi           CC                     In case of death, while performing duties, their widows/ dependants will also be eligible under                      “This application is for Rajiv Gandhi Gramin LPG Vitrak Yojana at ...........................
46     IOC                Jasipur                                     Mayurbhanj           CC                     this category.                                                                                                       (location) of ......................... (Name of Oil Company)”.
47     IOC                Thakurmunda                                 Mayurbhanj            O                     Candidate applying under this category should attach a copy of relevant certificate from the                 (i)     This is purely a business proposition and not an application for job in the respective Oil
48     IOC                Bisoi                                       Mayurbhanj            SC                    concerned Organisation/Govt Department signed by the Head of the Office or an Officer not                            Company and has normal business risks and also does not guarantee any assured
                                                                                                                  below the rank of Under Secretary to the Government.                                                                 returns or profits.
49     IOC                Nuapada sadar                                Nuapada              ST
                                                                                                                  iii) Physically Handicapped Category (PH)                                                                    (j)     This is only an application and not an offer of RGGLV.
50     IOC                Tangarpali                                  Sundergarh            O
                                                                                                                  Candidates would be considered eligible under this category in case the candidates are                                                                   APPLICATION FORM
51     IOC                Bonaigarh                                   Sundergarh            ST
                                                                                                                  orthopaedically handicapped to the extent of minimum of 40% permanent (partial) disability                          (FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)
52     BPC                Chandrapur                                   Rayagada             ST                    of either upper or lower limbs; or 50% permanent (partial) disability of both upper and lower         PLEASE READ GENERAL INSTRUCTION TO THE CANDIDATES BEFORE MAKING THE APPLICATION
53     BPC                R.Udayagiri                                   Gajapati            O                     limbs together. For this purpose, the standards contained in the ‘Manual for Orthopaedic
54     BPC                Jagannath prasad                              Ganjam              SC                    Surgeon in evaluating Permanent Physically Impairment’ brought out by the American Academy            For Office Use                                                            D D      -   M M     -    Y Y              Passport size
                                                                                                                  of Orthopaedic Surgeons, USA and published on its behalf by the Artificial Limbs Manufacturing                                                                                                                              photograph
55     BPC                Sankhemundi                                   Ganjam              O                                                                                                                          Not to be filled by applicant     Office Code             Serial No.       Date of receipt of application             with specimen
                                                                                                                  Corporation of India, G.T. Road, Kanpur, shall apply.                                                                                                                                                                       signature on
56     BPC                Kukudakhandi                                  Ganjam             CC                                                                                                                                            APPLICATION FOR RAJIV GANDHI GRAMIN LPG VITRAK YOJANA OF                                                  the
                                                                                                                  Deaf, Dumb and Blind persons with minimum degree of 40% disability will also be eligible to                                                                                                                                 photograph
57     BPC                Rasulpur                                       Jajpur             O                                                                                                                                          Please write name of Oil Company of the location (BPC or IOC or HPC)
                                                                                                                  apply for all RGGLVs/dealership under this category. However, totally blind persons will not
58     BPC                Tikabali                                    Kandhamal             O                     be eligible.                                                                                          Particular of application fee         Rs.
59     BPC                Kotagarh                                    Kandhamal            SC                     Candidate applying under this category should produce a certificate (as per the standard              Demand Draft Number                                                       Date D D - M M - Y Y
60     BPC                G.Udayagiri                                 Kandhamal             O                     format given the application format) issued by a Medical Board duly constituted by the Central        Drawn on (name of the bank)                                                    Payable At
                                                                                                                  / State Government as per the Gazette of India Extraordinary New Delhi, No 154 dated June             In favour of (Full name of the oil company)
61     BPC                Phiringia                                   Kandhamal            CC
                                                                                                                  13, 2001 on Guidelines for evaluation of various disabilities and procedure for certification.        (Enclose Application processing fee of Rs. 1000/- (One thousand only) for all applicants except
62     BPC                Daringibadi                                 Kandhamal             O
                                                                                                                  iv) Outstanding Sports Persons Category (OSP)                                                         SC/ST candidate. Application processing fee for SC/ST candidates in Rs. 500/- (Five hundred)
63     BPC                Khandapada                                   Nayagarh            SC                                                                                                                           on enclosing SC/ST certificate)
                                                                                                                  The following persons will be eligible :
64     BPC                Kakatpur                                        Puri             CC
                                                                                                                  (i) Arjuna/Khel Ratna Awardees.                                                                       1.       Name of the RGGLV Location
65     BPC                Shergarh                                      Ganjam              ST                                                                                                                          2.       Gram Panchayat
                                                                                                                  (ii) Winners of Medals at Olympics/Asian/Commonwealth Games and Recognised World
66     BPC                Dharakot                                      Ganjam              O                           Champions/World Championships.                                                                  3.       Rev. Distt.
67     BPC                Korei                                          Jajpur             O                     (iii) National Champions (First position) under the Recognised National Championships.                4.       State
68     BPC                Balichandrapur                                 Jajpur             ST                    (iv) National Adventure Awardees.                                                                     5.       Category
69     BPC                Chatia                                         Jajpur             O                     Candidate applying under this category should produce a certificate from the Recognised
                                                                                                                                                                                                                        OP, SC/ST, Combine Category (CC) Consisting of (DP/PMP/PH/OSP)
70     BPC                Balianta                                      Khurda              O                     National Federation Organising National Championships (as recognised by Department of
                                                                                                                  Youth Affairs and Sports, Govt of India) or from the Dept of Youth Affairs and Sports, Govt of        Please attach copy of certificates as proof from the respective competent authorities
71     BPC                Pichkuli                                      Khurda              ST                                                                                                                          as mentioned in the eligibility criteria. Not Applicable for locations under ‘Open’ category.
                                                                                                                  India.
72     BPC                Bolgarh                                       Khurda              O                                                                                                                           6.       Advertised on                D D          -    M M - Y Y Y Y              in (Please write Name of Newspaper)
                                                                                                        5.        Application can be made on plain paper (preferably typed) as per the prescribed format
73     BPC                Nuagaon                                      Nayagarh            CC                     given in this advertisement.                                                                          7. Particulars of Applicant - Enclose Affidavit as per format given in Appendix ‘A’)
74     BPC                Gania                                        Nayagarh             O           6.        APPLICATION PROCESSING FEE: Application to be submitted along with non-refundable                     7.1 Name
75     BPC                Sakhi Gopal                                     Puri              O                     fee of Rs 1000 (Rupees One thousand only) and in case of SC/ST candidates (SC/ST certificate                                            First Name                          Middle name                   Surname
76     BPC                Kanas                                           Puri             CC                     to be attached) Rs 500/- (Rupees five hundred).                                                       7.2 Father’s/      S H                     R       I
77     HPC                Kishorenagar                                   Angul              O           7.        APPLICATION (AS PER FORMAT GIVEN IN THIS ADVERTISEMENT) for RGGLV along                                   Husband’s Name Title                       First Name                 Middle Name               Surname

78     HPC                Narsinghpur                                   Cuttack             SC                    with enclosures complete in all respect and Non-refundable fee by a Demand Draft/Pay                  7.3 Address
                                                                                                                  Order drawn on any Scheduled Bank must be submitted so as to reach the office address
79     HPC                Gandia                                      Dhenkanal             O                     mentioned below before the close of office on 20.11.2009
80     HPC                Odapada                                     Dhenkanal             ST           Advertised locations Demand Draft/Pay                Payable at    Office Address for submitting
81     HPC                Kankadahada                                 Dhenkanal             O                                                                                                                                                                                                            Pin Code
                                                                                                                Sr. No        Order drawn on any                            application along with
82     HPC                Parjang                                     Dhenkanal            CC                                 Scheduled Bank                                enclosures and application                           Telephone No.                                                                          E-mail
                                                                                                           From         To    Drawn in favour of                            processing fee
83     HPC                Ali                                         Kendrapara            O                                                                                                                                                          STD code                Telephone Number
84     HPC                Kendrapada-Indupur                          Kendrapara           CC                     01           51    IndianOil Corporation Bhubaneswar Area Manager, Indane Area Office,                7.4 Indian Citizen   Yes                  No            Resident of             (Name of the village)

85     HPC                Marshaghai                                  Kendrapara            O                                        Limited (MD)                      IndianOil Corporation Limited (MD),                  Revenue District
                                                                                                                                                                       Alok Bharti (3rd Floor), Bhubaneswar-                State
86     HPC                Baipariguda                                   Koraput             ST
                                                                                                                                                                       751007, Ph : 0674-2542241/2542986
87     HPC                Pattangi                                      Koraput             O                                                                                                                           7.5 Gender                         Male / Female
                                                                                                                  52           76    Bharat Petroleum        Bhubaneswar Territory Manager (LPG), Bharat
88     HPC                Raikia                                      Kandhamal            CC                                        Corporation Limited                 Petroleum Corporation Limited, LPG             7.6 Date of Birth                 D D -        MM         - Y Y Y Y         Age         Years           Months             Days
89     HPC                Balimela                                     Malkangiri           ST                                                                           Bottling Plant & Territory Office, Plot        7.7 Marital Status                Single       /        Married       /    Widow / Widower                  /   Divorcee
90     HPC                Dabugaon                                   Nabarangpur            O                                                                            no.33, Industrial Estate, PO : PN              7.8 Name of Spouse
                                                                                                                                                                         College, Khurda, ORISSA – 752057
91     HPC                Kaniha                                         Angul              O                                                                                                                           8        Educational Qualification:
                                                                                                                                                                         Ph : 06755-223324/25
92     HPC                Gobra (Talcher Sadar)                          Angul             CC                                                                                                                                        Qualification                                                Board/University                Year of Passing
                                                                                                                  77           101   Hindustan Petroleum Bhubaneswar Sr.Regional Manager, Hindustan
93     HPC                Kalapathara                                   Cuttack             O                                                                                                                           i.           Graduate
                                                                                                                                     Corporation Limited             Petroleum Corporation Limited,
94     HPC                Naraj                                         Cuttack            CC                                                                        Bhubaneswar LPG Regional Office,                   ii.          Senior Secondary i.e. (10+2) CBSE
95     HPC                Raghunathpur                              Jagatsinghpur          CC                                                                        Jatni LPG Bottling Plant, PO :                                  or equivalent from recognised Board
96     HPC                Tirtol                                    Jagatsinghpur           O                                                                        Jatni Dist : Khurda, Pin-752050                    iii.         Matriculation i.e. Xth Standard examination
                                                                                                                                                                     Ph : 0674-2492912                                               or equivalent from recognised Board
97     HPC                Erasama                                   Jagatsinghpur           SC
98     HPC                Balikuda                                  Jagatsinghpur           O           8.        SELECTION PROCESS AND EVALUATION CRITERIA                                                                      Note : Marks will be awarded based on the information given by the applicant on the
                                                                                                                  All the applicants satisfying the eligibility criteria will be evaluated out of total 100 marks                educational qualification. On verification if it is found that the information given above is
99     HPC                Navgoan                                   Jagatsinghpur          CC                                                                                                                                    incorrect/false/misrepresented then the applicant's candidature will stand cancelled and
                                                                                                                  based on information given in the application. The evaluation will be done on the following
100    HPC                Derabisi                                    Kendrapara           SC                                                                                                                                    will not be eligible for RGGLV.
                                                                                                                  parameters:
101    HPC                Papadahandi                                Nabarangpur            O                                                                                                                           9.       Details of land for construction of LPG godown & showroom
                                                                                                             Sl. No       Parameter                                                    Max marks
Abbreviations used in ‘‘Category’’ column are : SC/ST - Scheduled Caste/ Scheduled                                                                                                                                               The land should be suitable, in contiguous plot, freely accessible through all weather
                                                                                                             1.           Financial Capability                                              50
Tribe Category, O - Open Category, CC - Combined Category consists of (I) Defence                                                                                                                                                motorable approach road. The plot should be free from live overhead power transmission/
Personnel (DP), (II) Paramilitary/ Police/ Government Personnel (PMP), (III) Physically                      2.           Income                                                            10                                   telephone lines. Pipelines/Canals/Drainage/Nullahs/Public Roads should not pass through
Handicapped (PH), (IV) Outstanding Sports Persons (OSP).                                                     3.           Educational Qualification                                         40                                   the plot. The land should be in advertised location. Dimension of the land should be -
2    Only Individuals are eligible to apply. However, on appointment all RGGLVs will be jointly in                                                                                                                               minimum 20 metre X 24 metre.
                                                                                                                  Selection for RGGLV will be done by draw of lot amongst all eligible applicants securing
     the names of applicant and his/her spouse (i.e wife/husband will be co-owner of RGGLVs). In                  minimum qualifying marks. Minimum qualifying marks is 60% for RGGLVs reserved under                            Do you own a suitable land at advertised location for
     case, the applicant is unmarried/divorcee/widow/widower, an undertaking will be required to                  SC/ST category and minimum 80% marks for all other category locations.                                         LPG godown & showroom?
     be given that after marriage/re-marriage, spouse will be made co-owner. There will be no                                                                                                                                        (Own means having clear ownership title of the property in the
                                                                                                                  Detailed guidelines including detailed criteria for evaluation and draw of lot is given in the
     educational qualification requirement for spouse.                                                                                                                                                                               name of applicant/family member of the ‘Family Unit’. Family
                                                                                                                  Brochure, which can be collected personally from the address mentioned at para 7 above at
3    COMMON ELIGIBILITY CRITERIA FOR ALL CATEGORIES :                                                             a cost of Rs.50/-. It is also available on the website of respective oil companies –www.iocl.com;                  Unit’ of a married applicant, shall consist of self, applicant's
     Applicant applying for RGGLV should                                                                          www.ebharatgas.com; www.bharatpetroleum.in and www.hindustanpetroleum.com                                          spouse and unmarried son(s)/daughter(s) and ‘Family Unit’ of                                 YES        /      NO
                                                                                                                                                                                                                                     a unmarried Applicant, shall consist of self, applicant's parents
     (a) be an Indian citizen.                                                                          9.        BASIC INFRASTRUCTURE FACILITIES REQUIRED FOR OPERATION OF RGGLV – LPG
                                                                                                                                                                                                                                     and applicant's unmarried brother(s)/ sister(s) for the purpose of
                                                                                                                  Storage Godown and Showroom.
     (b) be a resident of the town/village(s) of the advertised RGGLV location.                                                                                                                                                      this entire application. In case of family member, consent letter
                                                                                                                  RGGLV would require a storage Godown approved and licensed by Chief Controller of                                  from the family member will be required.)
     (c) have passed minimum Xth Standard examination or equivalent from recognised Board.
                                                                                                                  Explosives of Petroleum and Explosives Safety Organisation (PESO) for storage of LPG in
     (d) be not less than 21 years and not more than 45 years in age as on the date of application.                                                                                                                                        If ‘NO’, Applicant is not eligible                     Please strike off what is not applicable
                                                                                                                  cylinders. A showroom of the dimensions 2.6 m X 3 m is required to be constructed near the
     (e) fulfil Multiple Dealership/Distributorship norm.                                                         Godown or operated from an existing nearby shop.                                                               Provide the following details. In case land belongs to member of ‘Family Unit’, attach
                                                                                                                                                                                                                                 notorised affidavit as per Appendix-D
     Multiple Dealership/Distributorship norms means that the applicant or any other member of                    For construction of Godown, land should be of Minimum Dimensions 20 metre X 24 metre. It
     ‘family unit’ should not hold a dealership/distributorship/RGGLV or Letter of Intent (LOI) for a             should be freely accessible through all weather motorable approach road (public road or               Name(s) of the Relationship           Date of registration Address of the               Khasra           Dimension of land*
     dealership/distributorship/RGGLV of a PSU Oil Company i.e only one Retail Outlet/SKO-                        private road of the applicant connecting to the public road) and should be plain, in one              owner of Land with applicant          of sale deed/gift/ location of the               No/Survey
     LDO dealership/LPG distributorship/RGGLV of PSU Oil Company will be allowed to a ‘Family                     contiguous plot, free from live overhead power transmission or telephone lines. Canals /                                                    date of mutation      land or LPG                   No            Length in        Breadth in
                                                                                                                  Drainage/Nallahs should not be passing through the plot                                                                                                             Godown                                    Metre            Metre
     Unit’.
     ‘Family Unit’ in case of married person/ applicant, shall consist of individual concerned, his/              RGGLV will not be required to deliver LPG cylinders at the residence of the customers. LPG
     her Spouse and their unmarried son(s)/daughter(s). In case of unmarried person/ applicant,                   cylinders will be given to the customers from the authorised licensed LPG Godown at the                        *Give the dimensions of the plot that will be used for proposed godown out of
     ‘Family Unit’ shall consist of individual concerned, his/her parents and his/her unmarried                   Retail Selling Price(RSP).                                                                                     the total land owned by the applicant.
                                                                                                                                                                                                                                                                                                                                            Contd. to next page
Contd. from previous page
                                                                                                                                                  proof in support of the income indicated.                                                                                                                                      Appendix - C
  10 Financial Capability
                                                                                                                                                  e) Income from agriculture : A certificate from                                                                                                                           (NOTARISED AFFIDAVIT)
  Note : Marks will be awarded to the applicant on Financial Capability based on the information                                                  Mamlatdar/Tehsildar stating out clearly the                                                                                      (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
  given below by the applicant on Annual Income, Amount in Savings Bank Account/ Investments,                                                     location of the agricultural land the income                                                                                  (To be given by the family member as defined in eligibility criteria other than applicant)
  Value of Assets and Amount of loan from Banks/Financial Institution. On verification, if it is                                                  there from
  found that the information given by the applicant is incorrect/ false/ misrepresented then the                                                                                                                                                                         I, ........................................................... son/wife/daughter of ............................................ Age
                                                                                                                                      10.2        Amount in the Saving Account in the name of                                Notorised Affidavit as per
  applicant's candidature will stand cancelled and the candidate will be ineligible for this RGGLV.                                                                                                                                                                      .............................. years resident of .................. do hereby solemnly affirm and say as under :
                                                                                                                                                  self & the member(s) of the "Family Unit" as                               Appendix-C and Savings Bank
  10.1 Annual Income of Last Financial Year :                                   Rs                                                                on the date of application only will be                                    Accounts Statement/Pass Book                1.      That I am unmarried and my father*/mother*/unmarried brother*/unmarried sister* (Mr/Ms)
                                                                                                                                                  considered. Amount maintained in the joint                                 from which amount as on the date                    ................................................................ (name) has applied for RGGLV of IOC*/BPC*/HPC*
        Amount in words                                                                                                                           account with member(s) outside the                                         of application can be verified                      at .................................. (location) under ‘....................’ category against the advertisement
        If you are income tax payee/payer mention PAN mumber                                                                                      "Family Unit" should not be mentioned                                                                                          made in ............................ news paper dated ...............................
        Income pertaining to last Financial Year should be given. Attach notorised affidavit as                                       10.3        Investment in Fixed Deposit/Bonds/NSCs/                                    Notorised Affidavit as per                                                                                  OR
                                                                                                                                                  Mutual Funds/Shares/ULIP value as on Date                                  Appendix-C and original
        per Appendix-B                                                                                                                                                                                                                                                           That I am married and my unmarried son*/unmarried daughter*/wife*/husband* (Mr/Ms)
                                                                                                                                                  of Advertisement in the name of self and                                   investment documents based on
  10.2 AMOUNT IN SAVINGS BANK ACCOUNT as on the date of application in the name of                                                                member of the "Family unit".                                               which amounts has been                              ................................................................. (name) has applied for RGGLV of IOC*/BPC*/HPC*
       applicant and members of 'family unit'. For the amount mentioned against the member of                                                     Amount maintained in the joint account with                                mentioned in the application                        at .................................. (location) under ‘.......................’ category against the advertisement
       'family unit' marks will be awarded based on the amount mentioned in the affidavit made by                                                 member(s) outside the "Family Unit" should                                                                                     made in .........................news paper dated ..........................
       member(s) of 'family unit' the as per format given in Appendix-C.                                                                          not be mentioned. and will not be considered.                                                                                  * Strike off whichever is not applicable.
             Sl.    Name of         S.B.A/C          Name of      Relation with                   Amount as on date                               Fixed Deposit/Term Deposit etc in Bank-                                    Bank Statement or letter from the
                                                                                                                                                                                                                                                                         2.      That in case he/she is selected for RGGLV I will provide financial assistance to the extent of
             No.     Bank             No.        account holder(s) applicant                       of applicatiion                                amount as on the date of advertisement should                              Bankers certifying the amount in
                                                                                                                                                                                                                                                                                 Rs ...................................... which is mentioned at Item no.10 under my name in the application
                                                                                                                                                  be taken from the Bank                                                     FD/Term deposit as on the date
             1.                                                                            Rs.                     •                                                                                                                                                             submitted by (Mr/Ms) ........................................... for RGGLV of IOC*/BPC*/HPC* at
                                                                                                                                                                                                                             of advertisement
             2.                                                                            Rs.                     •                                                                                                                                                             ............................................
                                                                                                                                                  Investments in Mutual Funds/listed shares/ULIP                             Value on the date of
             3.                                                                            Rs.                     •                              based on the NAV on the date of advertisement.                             advertisement as certified by the           3.      That in case he/she is selected for RGGLV I have no objection for construction of godown/
             4.                                                                            Rs.                     •                                                                                                         Government Approved Valuer or                       showroom on the land specified in item no 9 in my name.
                                                         Total                             Rs.                     •                                                                                                         the concerned financial institution/                I hereby verify that what has been stated above is true and correct to the best of my knowledge,
                                                                                                                                                                                                                             certified by Chattered Accountant                   and nothing has been concealed therefrom
             Total amount in words
                                                                                                                                                  Amount of money which applicant can get on                                 Certificate from the Insurance
  10.3 FIXED DEPOSIT/NSC/SHARES/MF ETC as on date of advertisement in the name of                                                                 surrender of Insurance policy or as loan against                           Company                                             Solemnly affirmed and declared before me
       applicant and members of ‘Family Unit’. Attach affidavit as per format given in                                                            the policy as on the date of advertisment.                                                                                    This ...................... day of .....................
       Annexure-C from member(s) of ‘Family Unit’.                                                                                    10.4        Other assets/Property( immovable) in the name                              Valuation certificate by Govt.                     Signature and Seal of                                                           Signature of Deponent
             Sl.   Type of Doccument Name(s) Relation     Initial Value (Amount) as on the                                                        of the member of the "Family Unit" as on the                               Approved Valuer should give
             No. Investment Reference of the   with    investment date of advertisement                                                           date of advertisement. Assets/Property in the                              the the Value of assets as                         Magistrate/Judge/Notary public                                                 Relationship with applicant
                   FD/NSC/   Number   holder applicant Amount                                                                                     name of joint account of the member(s) outside                             prevailing on the date of
                   Shares/  with date                                                                                                             the "Family Unit" should not be mentioned.                                 advertisement. Date of Valuation                                                                Appendix - D
                    MF etc                                                                                                                        (Note: Gold should not be included). The                                   Certificate should between                  (Format for obtaining Credit worthiness certificate from the Bankers, from a Scheduled bank/
                                                                                                                                                  valuation of assets with regard to Land for                                date of advertisement and                   Financial institution on their Letter Head and enclosed with the application. Please note that
             1.                                                   Rs.                   •
                                                                                                                                                  godown mentioned in item 10 should not                                     date of application.                        amount must be mentioned. If no specific amount is mentioned no marks will be awarded.)
             2.                                                   Rs.                   •                                                         be included.
             3.                                                   Rs.                   •                                                                                                                                                                                                              TO WHOMSOEVER IT MAY CONCERN
                                                                                                                                      10.5        Amount based on the certificate/letter from a                              As per Appendix-D
             4.                                                   Rs.                   •                                                         Schedule Banks/Financial Institutions to extend                                                                        Shri/Smt/Kum/M/s,....................................... is a customer of this bank for last….............… Years
                                                                                                                                                  loan as per Annexure D. In case no specific                                                                            and he/she/they is/are enjoying the following facilities from our bank/institution :
                                       Total                      Rs.                   •
                                                                                                                                                  amount is mentioned then it shall be taken as                                                                                 a)
             Total amount in words                                                                                                                nil and no marks will be awarded.                                                                                             b)
  10.4 OTHER ASSETS/PROPERTY OF FAMILY as on the date of advertisement in the name of
                                                                                                                                     Important Note :                                                                                                                           c)
       applicant and members of ‘Family Unit’. Attach affidavit as per format given in
       Appendix-C form member(s) of ‘Family Unit’. (Note: Gold should not be included)                                               1. Family Unit’ of a married applicant, shall consist of self, applicant's spouse and unmarried                                     During the above period, the dealings of Shri/Smt/Kum/M/s ………………………..with the bank
                                                                                                                                        son(s)/daughter(s) and ‘Family Unit’ of a unmarried Applicant, shall consist of self, applicant's                                and his/her/their conduct has been satisfactory. In case, RGGLV is allotted to him/her/them, we will
        Value on the date of advertisement as certified by the Government Approved Valuer. The                                          parents and applicant's unmarried brother(s)/sister(s) for the purpose of this entire application.                               be willing to extend a loan of Rs………… (In words ............) towards financing the same.
        valuation of assets with regard to Land for godown mentioned in item 10 should not be
                                                                                                                                     2. Applicant should provide only that information in the application against various items, for
        included.                                                                                                                                                                                                                                                               Signature
                                                                                                                                        which applicant is in possession of supporting documents in original as on the date of submission
             Sl.       Details of the         Name of holder           Relation with       Value as per Government                      of application. Failure to present these documents in original at the time of verification can                                          Name and Designation
             No.       Property etc                                    the applicant       approved valuer                              result in cancellation of selection.                                                                                                    Office seal
             1.                                                                            Rs.                   •                   3. Incase applicant requires extra space for providing details on any point, the details can be                                            Date
             2.                                                                            Rs.                   •                      provided by adding extra rows or by adding extra sheets. However, details should be given in                                                                               STANDARD RESIDENCE CERTIFICATE
             3.                                                                            Rs.                   •                      the same format as mentioned in that particular point.
                                                                                                                                                                                                                                                                                                 (To given by the selected candidate at the time of Verification)
                                                                            Total          Rs.                   •                                                                      Check list for Applicants
                                                                                                                                                                                                                                                                         This is to certify that Shri/Smt/Kum ...................................................................................... son/
          Total amount in words                                                                                                           Sl.      Particulars to be checked                                                                          Check Box          daughter/wife of ......................................................................... is a resident of ( name of town/
  10.5 Details of the loan which can be obtained from Schedule Banks/Financial Institutions based                                         No.                                                                                                                            village) .................................... District ..................................... State ............................ for
       on Bankers/Financial Institution certificate to extend loan as per Annexure-D. If no specific                                      1        DD attached - verify amount, drawn in favour of                                                                       ........................ years.
       amount is mentioned then no marks will be awarded.                                                                                          concerned company and payable at
                                                                                                                                                                                                                                                                         This certificate is issued for the purpose of applying for Rajiv Gandhi Gramin LPG
             Name and address of the                             Date of Certificate                  Amount of Loan                      2.       Photograph pasted and signature across photograph                                                                     Vitarak Yojana at ................................... .
             Bank/Financial institution                                                                                                   3.       Eligibility certificate for the category attached as applicable
                                                     D    D      -    M     M        -   Y    Y                                           4.       Notorised Affidavit as per Appendix - A as applicable attached                                                                                                                                (............................................................)
       DECLARATION BY THE APPLICANT                                                                                                       5.       Notorised Affidavit as per Appendix - B as applicable
       I am aware that evaluation of candidates will be done based on the information given in the                                        6.       Notorised Affidavit as per Appendix - C                                                                               Date ..................................                                                 Signature of
       application above. On verification by the Oil Company if it is found that the information given                                    7.       Certificate as per Appendix - D as applicable                                                                                                                                                            Dy. Tehsildar/Tehsildar
       by me is incorrect/false/misrepresented then my candidature will stand cancelled and I will                                                                                                                                                                       Place ................................                                            Dy. Mamlatdar/Mamlatdar
                                                                                                                                          8.       Declaration by Applicant at the end is duly signed with name,                                                                                                                                                (Seal of Office)
       be declared ineligible for RGGLV. I also confirm that I am in possession of the supporting                                                  date and place
       documents in original in respect of the information given by me in this application and if                                                                                                                                                                                                 STANDARD FORMAT FOR SC/ST CATEGORY CERTIFICATE
                                                                                                                                          9.       All pages of application are numbered and signed
       selected, failure to present these documents in original will result in cancellation of selection
       due to submission of false/unsupported information in this application.                                                            10.      The Application is complete in all respect                                                                            Note: A candidate who claims to belong to one of the Scheduled Castes / Scheduled Tribes should
                                                                                                                                                                                                                                                                         submit in support of his/her claim, a certificate in original, with a copy thereof in the form given
       I am fully aware that after selection if I am unable to provide LPG Godown duly approved by
                                                                                                                                                                                                                                                                         below, issued at any time by a competent authority # notified by the Government of India, of the
       the Office of Chief Controller of Explosives (PESO) and Showroom as per the Oil Company’s                                                                                                Appendix - A                                                             district in which his parents (or surviving parents) ordinarily reside who has been designated by the
       standard layout, then the offer of RGGLV made to me will automatically stand cancelled.                                                                                         (NOTARISED AFFIDAVIT)                                                             State Government concerned as competent to issue such a certificate. If both his parents are dead,
       I am fully aware that I will not be appointed as RGGLV if I am employed. I shall have to resign                               (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)                                                             the officer signing the certificate should be of the District in which the candidate himself ordinarily
       from the service and produce proof of acceptance of my resignation from my employer before                                    I,............................................Son/Daughter/wife of ................................................. Age            resides otherwise than for the purpose of his own education. In case of any doubt about the
       issuance of Letter of Appointment.                                                                                            .................................. years residing at ................................ do hereby solemnly affirm and                 genuineness of the certificate, the same may be got verified through the concerned District Magistrate
       I am aware that if married, my spouse will be co-owner of RGGLV with me.                                                      say as under :                                                                                                                      / Deputy Commissioner.
       That, if selected, I undertake that I will deposit an interest free Security as per the policy of the                         1. That I am an Indian Citizen and resident of (Name of Village), (Gram Panchayat), (District) in                                   The form of the certificate to be produced by Scheduled Castes / Scheduled Tribes candidates.
       Corporation.                                                                                                                        the State of ........................................
                                                                                                                                     2. That my date of birth is                    d d / m m / y y y y (in words___________________)                                    This is to certify that Shri/Smt./Kum*............................. son/daughter* of .......................... of village/
       I have read the terms and conditions applicable for the RGGLV mentioned in the advertisement                                                                                                                                                                      town *.............................. in District/Division* ....................... of the State/Union/ Territory* of
       and confirm that I fulfil the eligibility criteria for the RGGLV I have applied for in this application.                                                                                                                                                          .......................... belongs to the ..................... Caste/Tribes and his/her religion is .................................
                                                                                                                                     3. That I have passed Std X or equivalent examination in the year                           y y y y
       I, .................................................................................. daughter of/son of/wife of Shri                                                                                                                                             which is recognised as a Scheduled Castes/Scheduled Tribes under the Scheduled Castes/
                                                                                                                                                                                         and
       ................................................................ hereby confirm that the information given above is               That I have passed Senior Secondary i.e.(10+2) CBSE or                                  y y y y                                 Scheduled Tribes lists (modification) order 1956* read with the Bombay Re-organisation Act, 1960
       true and correct. Any wrong information/misrepresentation/ suppression of facts will make                                         equivalent examination in the year*                                                                                             and the Punjab Reorganisation Act 1956*.
       me ineligible for this RGGLV.                                                                                                                                                   and                                                                               The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956*
       Place : ........................................                Signature of applicant ....................................       That I have passed Graduation examination in the year*                                  y y y y
                                                                                                                                                                                                                                                                         The Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1956*
       Date : d d - m m - y y y y                                      Name of applicant .......................................     4. That I am unmarried. That neither I, nor my Father, Mother, unmarried brother(s), unmarried
                                                              (In block letters)                                                         sister(s) have dealership/distributorship or hold Letter of Intent for Retail Outlet or SKO-LDO                                 The Constitution (Dadra & Nagar Haveli) Scheduled Castes Order, 1962*
     List of Enclosures :                                                                                                                dealership or LPG distributorship or RGGLV of any Oil Company.                                                                  The Constitution (Pondicherry) Scheduled Castes Order, 1964*
     1. Attested copy of Eligibility Certificate for the category applied.                                                                                                             OR                                                                                The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967*
     2. Demand Draft No. ................................ dated ......................................                                   That I am married and name of my spouse is _____________That neither I nor my spouse,
                                                                                                                                         unmarried son(s)/unmarried daughter(s) have dealership/distributorship or hold letter of Intent                                 The Constitution (Nagaland) Scheduled Tribes Order, 1970*
     3. Affidavit in original as per the format in Appendix A
                                                                                                                                         for Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV of any Oil Company :                                    Place : .............................                      Signature : ....................................
     4. Affidavit in original as per the format in Appendix B
                                                                                                                                                                                       OR                                                                                Date : ..............................                      Designation : ................................. (with seal of office)
     5. Affidavit in original as per the format in Appendix C
                                                                                                                                         That I am widow/widower. That neither I nor my unmarried son(s)/unmarried daughter(s)
     6. Letter from Bank/Financial Institution in original as per format in Appendix-D                                                                                                                                                                                   State/Union Territory*
                                                                                                                                         (whose custody is given to me) have dealership/distributorship or hold letter of Intent for
                       Total number of pages of the application including attachments                                                    Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV of any Oil Company :                                        * Please delete the words which are not applicable.
                     General Instructions to the candidates applying for RGGLV                                                                                                         OR                                                                                (Note : The terms “Ordinarily reside(s)” used here will have the same meaning as in Section-20 of
                                                                                                                                         That I am divorcee. That neither I nor my unmarried son(s)/unmarried daughter(s) have                                           the Representation of the People Act, 1950.)
Item     Instructions                                                              Supporting Documents to                               dealership/ distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or
                                                                                                                                                                                                                                                                         # Officers competent to issue Caste/Tribe certificates.
No.                                                                                be provide by applicant at                            LPG distributorship or RGGLV of any Oil Company:
                                                                                   the time of verification                          5. That I am of sound mental health.                                                                                                i.      District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional
1.       Write the name of the location for which                                                                                    6. That I have never been convicted nor charges have ever been framed against me by any                                                     Deputy Commissioner/Deputy Collector, 1st Class Stipendiary Magistrate/City Magistrate ***
         application is made as per advertisement                                                                                        Court of Law for any criminal offences involving moral turpitude and/or economic offences                                               Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant
2.       Write the name of the Gram Panchayat of the                               As per advertisement                                  (other than freedom struggle).                                                                                                          Commissioner.
         location for which application is made as per                                                                               7. That I hereby confirm that I was never a signatory to dealership/distributorship agreement of                                            *** (Not below the rank of 1st Class Stipendiary Magistrate)
         advertisement                                                                                                                   any Oil Company, which was terminated for proven malpractices and/or for violations of
                                                                                                                                         provisions of the Marketing Discipline Guidelines.                                                                              ii.     Chief Presidency Magistrate/Additional Chief Presidency Magistrate, Presidency Magistrate.
3.       Write the name of the district of the location for
         which application is made as per advertisement                                                                              8. That if any information/declaration given by me in my application or in any document submitted                                   iii.    Revenue Officers not below the rank of Tehsildar.
4.       Write the name of the State of the location for                                                                                 by me in support of application for the award of the RGGLV or in this affidavit shall be found                                  iv.     Sub-divisional officer of the area where the candidate and/or his family normally resides.
                                                                                                                                         to be untrue or incorrect or false, the Indian Oil Corporation*/Bharat Petroleum Corporation*/
         which application is made as per advertisement                                                                                                                                                                                                                  v.      Administrative/Secretary to Administrator/Development Officer (Lakshadweep).
                                                                                                                                         Hindustan Petroleum Corporation* would be within its rights to withdraw the letter of intent/
5.       Write the name of the category of the location                            Certificate issued by the                             terminate the distributorship (if already appointed) and that I would have no claim, whatsoever,
         as per the advertisement                                                  competent authority. Caste                                                                                                                                                                                STANDARD FORMAT FOR PH CATEGORY CERTIFICATE
                                                                                                                                         against the Corporation for such withdrawal/termination.
                                                                                   validity Certificate as applicable                                                                                                                                                               NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE
                                                                                                                                     * Strike off whatever is not applicable.
6.       Write the date and name of the news paper                                                                                       I hereby verify that what has been stated above is true and correct to the best of my knowledge                                 Certificate No.
         in which advertisement has appeared for the                                                                                     and nothing material has been concealed therefrom.                                                                              Date
         location mentioned in item 1.
                                                                                                                                         Solemnly affirmed and declared before me                                                                                                                     CERTIFICATE FOR THE PERSONS WITH DISABILITIES
7.       For Item No. 7.1 to 7.8                               Notorised Affidavit-A to be
                                                               submitted. A residency certificate                                          This ...................................... day of .......................................
                                                                                                                                                                                                                                                                         This is to certify that Shri/Smt./Kum....................... wife/daughter/son of Shri ............................ Age
                                                               in the standard format from the                                                                                                                                                                           ......................... old male/female, Registration No. ....................................... is a case of physically
                                                               competent authority                                                         Signature and seal of                                                     Signature of person making affidavit                disabled/visual disabled/speech & hearing disabled and has .................................... %
8.       Education - Information in chronological order        Original certificate for each                                               Magistrate/Judge/Notary Public                                                  (Name in block letters)                       (.....................................) permanent (physical impairment/visual impairment/speech & hearing
                                                               qualification                                                                                                                Appendix - B                                                                 impairment) in relation to his/her ...................................................................................
9.       Details of land for construction of godown & showroom : In case applicant does not                                                                                            (NOTARISED AFFIDAVIT)                                                             Note:
         provide any information, then it will be deemed that applicant does not have required                                                    (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAM PAPER OF REQUIRED VALUE)
         land and hence applicant will be ineligible for RGGLV                                                                                                                                                                                                           1.      This condition is progressive/non-progressive/likely to improve/not likely to improve*.
                                                                                                                                                                              DECLARATION OF ANNUAL INCOME
         Please provide the details of Land as per             Registered Sale Deed/Gift Deed/                                                                                                                                                                           2.      Re-assessment is not recommended/is recommended after a period of ........................... months/
         the format                                            Mutation and government record                                        I,....................................................son/daughter/wife of .................................................. Age           years.
                                                               etc. The date of the documents                                        ........................... years residing at .....................................................do hereby solemnly affirm and
                                                                                                                                                                                                                                                                                 *Strike out which is not applicable.
                                                               have to be on or before the date                                      declare details of my gross annual income as under :
                                                               of application. Consent from the                                                                  Please give details of income of the last financial year (20--/--)                                                 Sd/-                                        Sd/-                                     Sd/-
                                                               family member in form of                                                                             Gross income should be indicated and not net income
                                                               Notorized Affidavit (Appendix-C)                                                                                                                                                                                  (DOCTOR)                                    (DOCTOR)                                 (DOCTOR)
                                                               is required. If required, certificate                                                                      Details of Gross Annual Income in Rupees                                                                  Seal                                        Seal                                     Seal
                                                               from the concerned authority                                           Relationship Gross             Property Interest/ Business Professional  Income        Income     Total                            Signature/Thumb impression of the patient
                                                               stating that the land is free from                                                  Salary              (net   Dividend (Net profit) Income       from      from other   (I+II+
                                                               live overhead power transmission                                                                                                                                                                          Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)
                                                                                                                                                                     income)                          (Net of Agriculture sources e.g. III+IV+
                                                               or telephone lines                                                                                                                   expenses)   (Net of   pension, etc. V+VI+                            Recent Attested PhotographShowing the disability affixed here.
10.      Financial Capability                                                                                                                                                                                 expenses)                  VII)
10.1     Gross Annual Income of the "Family Unit" for          Notorised Affidavit as per                                                                                                                                                                                                   STANDARD FORMAT FOR PARAMILITARY/POLICE/GOVERNMENT
                                                                                                                                                             I          II        III       IV          V          VI          VII       VIII
         the last financial year. The income should            Appendix-B and all the                                                                                                                                                                                                                      PERSONNEL CATEGORY
                                                                                                                                      1. Self
         include income from all sources such as               documents based on which the                                                                                                                                                                              Certificate is to be given by Head of the Office or an Officer not below the rank of Under Secretary
         salary, property, interest, dividend, business/       income is shown in the Affidavit                                       2. Spouse
                                                                                                                                                                                                                                                                         to the Government on Official Letter-Head of the Organization/Government Office issuing the
         profession/vocation, agriculture and other                                                                                   3. Unmarried                                                                                                                       Certificate.
         sources, if any.                                                                                                                son/
                                                                                                                                        daughter                                                                                                                                   NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE
         If the applicant is an Income Tax Assessee, the
         details of income as shown in the Annual Income                                                                               In case Applicant is unmarried, income of mother, father, unmarried brother(s)/unmarried sister(s) can be                         Reference No.
         Declaration should conform to those indicated                                                                                                       given in case notarised affidavit as per Appendix-C is attached                                             Date
         in the income tax return for the relevant                                                                                    Father
         financial year.                                                                                                                                                                                                                                                             Eligibility Certificate for Paramilitary/Policy/Government Personnel Category
                                                                                                                                      Mother                                                                                                                             I.      This is to certify that Mr/Ms (name of applicant) ........................................ was working in our
         If, however, the applicant is not an Income
         Tax Assessee then the details are required to                                                                                Unmarried                                                                                                                                  organisation ................... and has been disabled on (date) ..................... while performing
         be supported with other relevant document(s)                                                                                 sister(s)/                                                                                                                                 duties at (place) .........................
         some of which are mentioned below for                                                                                        brotehr(s)
                                                                                                                                                                                                                                                                                                                                         OR
         illustration purpose only.
                                                                                                                                     I hereby declare that I am an Income Tax payer and I am attaching here with the copy of my                                          II.     This is to certify that Mr/Mrs ....................................... who was working in this office as
         a) Gross Salary : A certificate from the                                                                                    Income Tax Return for the above Financial Year*
         employer(s) indicating the total emoluments paid                                                                                                                                                                                                                        .............. had passed away on (date) .................. while on duty at (Place) ............
         b) Income from property : Rent as declared                                                                                  I hereby declare that I am not an Income Tax payer*                                                                                         Mr/Ms (name of applicant) ....................... (relationship .....................) was dependent on Mr/
         and assessed for the purpose of tax.                                                                                        *Strike off whichever is not applicable                                                                                                     Ms .............................. as per our records.
         c) Interest on Bank Deposits : Letter issued                                                                                Solemnly affirmed and declared before me
         by competent authority from Bank(s) showing
                                                                                                                                     This ....................... day of .....................                                                                                   Attested Signatures of applicant
         the actual amount paid/credited as interest.
         d) Income from business/profession/vocation/                                                                                Signature and Seal of                                                                              Signature of Deponent                    Place : ................................                                Signature
         shares and other investment/other sources :                                                                                 Magistrate/Judge/Notary public                                                                     (Name in block letters)
         Certificate from Chartered Account in support                                                                                                                                                                                                                           Date : ................................                                 Name :
                                                                                                                                     1.        It is important to give precise information under each head i.e. I to VII, if income under any
         of the income indicated under each of these                                                                                                                                                                                                                                                                                                     Designation :
         heads will be required. The applicant may also                                                                                        head is NIL, then it should be indicated specifically as NIL and not left blank.
                                                                                                                                                                                                                                                                                                                                                         Office Seal :
         be required to produce any other documentary                                                                                2.        If the applicant is payee of Income Tax, a copy of Income Tax Return should be attached.