Finance Department, Government of Andhra Pradesh

Home Guards/ Anagnwadi Worker/ Anganwadi Helper/ ASHA/Gopal Mitra/Adarsh Raithu/Vidya Volunteer/Other Details Note : Please read the Guidelines sent by Department before filling the form, in CAPITAL LETTERS in blue/ black ball point pen only. (Please avoid Short Forms and Abbreviations)

1.Key Employment Details 1.1 Employee ID 1.2 Employee Type

Homeguard/ Anganwadi Workers/ ASHA/ Mandal Samkya/ Gopal Mitra/ Anganwadi Helper/ Vidya Volunteers/ Village Samkya/ Zilla Samkya/ Village Servant/ Village Revenue Assistants/ Adarsh Raitu/ Others __________________________________________ (Please Select the applicable type)

1.3 Surname(ఇంటి పేరు) 1.4 Name

1.5 Gender

Male

Female

1.6 Father / Husband

Father

Husband

Father / Husband Name 1.7 Date of Birth

/

1.8 Marital Status

/

Single

Married

Daily

Monthly

SC

ST

(DD/MM/YYYY) Divorced

Widow

Widower

For Night

Others

1.9 Place of Birth District Mandal Village 1.10 Place of Initial Appointment District Mandal Village 1.11 Terms of Payment

Weekly

1.12 Remuneration 1.13 Office in Which Employee is Working: 1.14 Head of Account: 1.15 Mobile No. 1.16 Personal E-Mail Id 1.17 Community

Minority

BC –A

BC-B

BC-C

BC-D

BC-E

Others 2. Bank and Other key Details

2.1Date of Entry into Service:

/

/

(DD/MM/YYYY)

2.2 Aadhar No 2.3 PAN 2.4 Bank Name 2.5 District of the Bank Branch 2.6 Bank Branch

Page 1 of 2

Finance Department, Government of Andhra Pradesh

Home Guards/ Anagnwadi Worker/ Anganwadi Helper/ ASHA/Gopal Mitra/Adarsh Raithu/Vidya Volunteer/Other Details Note : Please read the Guidelines sent by Department before filling the form, in CAPITAL LETTERS in blue/ black ball point pen only. (Please avoid Short Forms and Abbreviations) 2.7 Bank A/C No 2.8 IFS Code

DECLARATION* The above information is true to the best of my knowledge. I agree to share details of self and family with Government of Andhra Pradesh. I am aware that declaration of wrong details will entail disciplinary action against me.

__________________ Individual’s Signature

Date:

__________________ DDO’s Signature

Date:

Page 2 of 2

Home Guards/ Anagnwadi Worker/ Anganwadi Helper/ ASHA/Gopal ...

Note : Please read the Guidelines sent by Department before filling the form, in CAPITAL. LETTERS in blue/ black ball point pen ... BC-C. BC-D. BC-E. Minority. Others. 2. Bank and Other key Details. 2.1Date of Entry into Service: /. /. (DD/MM/YYYY). 2.2 Aadhar No. 2.3 PAN. 2.4 Bank Name. 2.5 District of the Bank Branch.

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