Application Form for Grant of ACP, level under Haryana Civil Services (ACP) Rules 2016

Application Form for Grant of ACP Level

Under Haryana Civil Services (ACP) Rules 2016

(As per F.D. Hr. Govt. Notification No. 1/20/2016(ACP)-5PR(FD) dated 28.10.2016)

Section 1: Personal Details

1. Name of the Employee:

Employee ID Number:

2. Designation:

3. Group: Select Group Group I Group II Group III Group IV

4. Existing Pay Level:

5. A.C.P. Level (Demanded): Select ACP Level ACP Level I ACP Level II ACP Level III

Present Place of Posting:

Section 2: Service Record

6. Date of Regular Appointment:

Date of 1st Entry in Service:

Post on which recruited as direct entrant:

7. Promotion Details (if any):

Date of Promotion:

Name of Post:

Pay Structure:

8. Number of Financial Upgradations Received:

Dates of Financial Upgradations:

1st Upgradation:

2nd Upgradation:

3rd Upgradation:

Section 3: Leave and Non-Qualifying Service

9. Duration of Non-Qualifying Service:

Period of Extraordinary Leave (other than medical):

10. Date of Completion of Required Years of Service:

Years Completed: Select 8 Years 16 Years 24 Years

11. Due Date of Next ACP Level:

12. Admissibility of A.C.P. Level Date:

Section 4: Overall Assessment of ACRs

Sr. No.	Period of ACR	Grading	Integrity (Good/Doubtful)
1			Select Good Doubtful
2			Select Good Doubtful
3			Select Good Doubtful
4			Select Good Doubtful
5			Select Good Doubtful
6			Select Good Doubtful
7			Select Good Doubtful
8			Select Good Doubtful
9			Select Good Doubtful
10			Select Good Doubtful

Whether 70% service record is good as per ACR summary:

YES NO

Section 5: Eligibility and Verification

12. For which ACP level the employee is eligible: Select ACP Level I ACP Level II ACP Level III

13. Whether service verification has been done completely:

YES NO

14. Whether employee is fit for promotion (Rule 8):

YES NO

15. Any complaint/enquiry pending:

YES NO

If yes, provide details:

16. Whether employee has foregone promotion at any level:

YES NO

17. Whether any recovery is pending:

YES NO

Recovery details:

18. Competent Authority for grant of ACP:

Section 6: Pay Fixation

Basic Pay as on 01.01.2016:

ACP Pay Band and Grade Pay:

Revised Basic Pay (calculated):

Date of Next Increment:

Pay after Increment:

Section 7: Service Verification Chart

Sr. No.	Qualifying Service Period		Service Book Ref.	Non-Qualifying Service		Reason	Service Book Ref.	Action
	From	To	Part & Page	From	To		Part & Page
1
2
3

Section 8: Certificates

No Complaint/Enquiry Certificate

It is certified that Mr./Ms. is working as in on regular basis since and no enquiry/complaints pending against him/her.

Date:

Station:

Head of Office

Certification Regarding Integrity

It is certified that Mr./Ms. is working as in on regular basis since and his/her work and conduct remained most satisfactory and integrity is above board.

Date:

Station:

Head of Office

Section 9: Result Sheet (For Teaching Staff)

Sr. No.	Name of Examination	Subjects	No. of Students	No. Passed	Pass %	Board/Dept. %	Difference	Action
1
2
3

Section 10: Undertakings

Undertaking 1

I hereby undertake that any excess payment that may be found to have been made as a result of incorrect fixation of pay or any excess payment detected in the light of discrepancies noticed subsequently will be refunded by me to the Government either by adjustment against future payments due to me or otherwise.

Date:

Station:

Signature of Employee

Undertaking 2

I hereby undertake that as a result of any rectification or adjustment in the pay matrix granted to me on the strength of any interim order by any Court of Law, any excess amount which may be found to have been made will be refunded by me to the Government either by adjustment against future payments due to me or otherwise. I further undertake to abide by such relevant appropriate decision of the Government taken on the final decision of such Court of law.

Date:

Station:

Signature of Employee

Section 11: Official Verification and Signatures

Prepared by	Checked by	Checked by	Checked by	Checked by
(School Clerk)	(Principal) with stamp	BEO/BEEO with stamp	(Dealing Asstt./Clerk) O/o DEO/DEEO	(Superintendent) with stamp

Section Officer Remarks

Approved & Counter Signed

Concerned employee is entitled/not entitled for ACP Level as 1st/2nd/3rd ACP w.e.f under rule of HCS (ACP) Rules, 2016 subject to fulfillment of other general conditions laid down in rule .

Section Officer O/o DEO/DEEO with stamp

(DEO/DEEO) with stamp

Date:

Signature of the Employee

Name:

Designation:

Office: