APPLICATION FOR PAY/WAGE REVISION ARREARS FOR THE PERIOD 01.01.1997 TO 30.06.2001

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

Name*

Badge No.*

Division*

Department*

Designation*

Reason for separation*

Death Date*

Date of Separation*

No of Legal Heirs*

(Please attach Death Certificate and Legal heirship Certificate/Certificate of Administration along with the Life Certificate of the Legal heirs)