FACT

I) EMPLOYEE SERVICE DETAILS (at the time of separation)

Name*

Badge No.*

Designation*

Department*

Division*

Date of separation*

Reason for separation*

(Please attach Life Certificate in the format available in the Website issued by a Gazetted Officer or from a Serving Officer in the level of DGM or above of FACT, along with the printout of the application.)

II) EMPLOYEE CONTACT DETAILS

Mobile No.*

Alternate mobile no*

Email id*

Address*

III) EMPLOYEE - BANK / AADHAAR/ PAN DETAILS

Name of Bank*

IFSC Code*

Branch*

Bank Account No.*

AADHAAR No.*

PAN No.*

(Please attach self attested copy of 1) first page of Bank Pass book/Cheque leaf/Bank Statement with all above details of Bank/ Bank Account 2) PAN card and 3) Aadhaar Card, along with the printout of the application.)

I hereby execute irrevocable undertaking that I shall abide by the Scheme titled “Scheme for payment of Pay / Wage Revision Arrears for the period 01.01.1997 to 30.06.2001” drawn by the FACT Management and covered by the Order in SLP 5896-5899/2020 of the Hon’ble Supreme Court of India. I solemnly affirm that I shall not claim interest on the amount being released towards Pay/Wage revision arrears for the period 01.01.1997 to 30.06.2001 and hereto give my irreversible consent to settle my PF account accordingly.

I Accept

Application for PAY/WAGE REVISION ARREARS FOR THE PERIOD 01.01.1997 TO 30.06.2001