1.            Name of the applicant                                     :

2.    (a)    Department to which attached with the name   :

                and address of the office/institution in which


        (b)    Designation                                                    :

        (c)    Place of  Posting                                            :

        (d)    Date of Joining in the Present Posting             :

3.              Post Permanent or temporary other than        :

                 step gap or extra temporary post held by the


4.              Scale of pay (Revised/Unrevised)                  :    Revised/Unrevised

5.              Permanent monthly basic pay (including         :

                 special pay/O.P. or per scale/unrevised scale :

6.              Type of  Flat applied for                                :

7.              Present residence and rent paid therefore       :

8.              Special reason for supply for the quarter,       :

                 if any.

9.              Whether the applicant possess any home in    :

                 his name or in the name of his wife in and

                 around Calcutta.

10.            Name of Father/Husband/Wife with               :

                 occupation and monthly income, if any.

11.            Total numbers of members in the family with   :

                 name and age.

12.            Details of earlier application made for Flats,    :

                 in any application with date receipt given by

                 this office/Assistant Engineer's if any, copy to

                 be submitted.


                 I declare at the particulars, given above, are true and in case of a flat being allotted to me,  I agree to pay rent there as may be fixed by Govt. from time to time direct or under deduction from my salary at monthly rate as may be decided by govt. and also undertake to abide all the terms and conditions as may be laid down by Govt. to given tenancy of quarters. In the event of my ceasing to be in the employment of Govt. to given tenancy of quarters. In the event of my ceasing to be in the employment of Govt. of West Bengal or being transferred to an another station, I further undertake to hand over vacant possession of the flat as may be allotted to within one month from the date I cease to be  a Govt. employees or an transferred.


                 In the event of my retirement from the Govt.  Service, my dues towards H.R. if any be deducted from my pension/gratuity benefits.



_____________________________________                              ___________________

Attestation & recommendation of the Department.                            Signature of the Applicant.