GVVK

Annexure – II

G.O.Ms.No.53, SW (TW.Ser.III) Dept., Dt. 28-6-2005

Application seeking transfer through counseling

(to be filled in by the applicant teacher/ Hostel Welfare Officer)

1. Name of the teacher / Hostel Welfare Officer:

Gender :	M F
Qualification
Date of Birth	D D M M Y Y
Present post held
Posts and tenure starting with present post.

Sl.No	Post & place held	From (dd/mm/yyyy)	To (dd/mm/yyyy)
I
Ii
iii
iv
V

Special Considerations:

1. Whether seeking retention beyond (8) years at the place/or/transfer without completing (3) years tenure.

Y

N

2.2 If so under which category? (Please fill in the code number and for code
numbers see below)

2.3 Whether principal office (Dist. / State Level) bearer of any recognized service
association (if so furnish a certificate/ documentary proof from State body)

Y

N

4. Whether taking up NCC/ Scouting program in the school?

Y

N

5. Whether yourself along with your spouse willing to work in a category – IV

institution, if so mention the preferential location.

Y

N

Name of the institution and place

2.6 In case your spouse is working in a non-transferable post, please furnish the
details along with a certificate from employer /head of the institution.

Y

N

Entitlement points

3.1 places worked for the last (8) years (please see para 11.A (i) of the
G.O.Ms.No.53, SW (TW.Ser.III) Dept., Dt. 28-6-2005)

From	To	Name of the institution	Location falls under which category	No.of points earned as per location of the institution

3.2 Results secured in ClassVII in case of UP School / Class X in case of High School
(Please see para 11.C (i) of the G.O)

Year	No. appeared	No passed	% Pass	Points earned
2009

3. Status of enrolment /retention as on 23/4/2005 (Academic performance) (for Primary Schools only) (Please see para 11.B(i) of the G.O.)

No. of school age children as per school census register	Admitted as on 31-07-2008	Total children on the rolls of the school as on 23-4-2009	% enrolment	% retention	Points earned for enrolment

Points earned for enrolment and retention put together	Total

4. Non-academic participation (for all Schools) (Please see para 11.A(ii) of the G.O)

Sl. No.	Level of various competitions	No. of Children sponsored 2008-09	Event	Date	Points earned
1	District Level
2	State Level
3	National Level

(Please attach proof from Head of the Institution)

3.5 Non-academic achievement (for all Schools): (Please see para 11.A. (iii) of
the G.O.Ms.No.53, SW (TW.Ser.III) Dept., Dt. 28-6-2005)

Sl. No.	Level	No. fo Prizes Merit certificates received by the Children during 2008-09	Event	Date	Points earned
1	District Level
2	State Level
3	National Level

(Please attach copies of certificates)

6. Professional achievements of staff: (Please see para 11.A(iv) of the G.O)

Sl. No.	Nature of award received	Date	Awarding authority	Points earned
1.
2.
3.

3.7 In case of Primary Schools (for improving retention of girl children) (Please
see Para 11.B (ii) of the G.O.Ms.No.53, SW (TW.Ser.III) Dept.,
Dt. 28-6-2005)

Total girl children enrolled in the school during 2007-08 (as on 31-7-2008)	Total girl children on the roll of the school as on 23-4-09	% retention	Points earned for retention of girl children

3.8 Retention in Upper primary /High Schools (please see para 11.C (ii) of the
G.O.Ms.No.53, SW (TW.Ser.III) Dept., Dt. 28-6-2005)

Enrolled as on 31-7-2008

In the roll as on 23-4-2009

% retention

Points earned

9. Total entitlement points earned

120

for Upper Primary Schools and High Schools

(3.1+3.2+3.4+3.5+3.6+3.8)

2. for Primary Schools

(3.1+3.3+3.4+3.5+3.6+3.7)

3.10(i) I certify that the above information furnished is true to best of my
knowledge. I will be liable for disciplinary/ prosecution in the event any
information is found to be wrong .

Name and Signature of the applicant

3.10 (ii) I have verified the data with the Service Register of the individual
and also with available schools record and I attest the correctness of
the data furnished above.

Signature of the Headmaster/ Headmaster of Paycenter

(for Teachers of Ashram Schools/ Primary Schools)

I have verified the date with the Service Register of the individual
and also with available school/hostel record and I attest to the
correctness of the data furnished above.

Signature of the DTWO

(for Headmasters of Ashram Schools and Hostel Welfare Officers)

Code Numbers:

Sl. No.	For filling up column 1.3	Code Nos.	For filling up column 2.2	Code
01	P.G. Headmasters	01	Physically challenged (70% and above)	01
02	School Assistant (Science)	02	Single Women	02
03	School Assistant (English)	03	Major Surgical Operation	03
04	School Assistant (Maths)	04	Having Mentally challenged children	04
05	School Assistant (Social Studies)	05
06	Telugu Pandit Gr. - I	06
07	Telugu Pandit Gr. - II	07
08	Hindi Pandit	08
09	Physical Education Teacher	09
10	Secondary Grade Teacher	10
11	Musical Training Instructor MUSIC/Dance/Craft	11
12	Hostel Welfare Officer Gr. II	12
13	Hostel Welfare officer Gr.I	13

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