Form-V

(See regulation (23) )

Service Book


1. Name in Full :-
2. Permanent Address :
3. Local Address :
4. Date of Birth (Both in words and figures) :
5. Details of the evidence on which the date of birth has been recorded in the Service Book (viz. RSC/SSC Matriculation Certificate etd. )
6. (A) Mother-tongue :
(B) Language through the medium of which the teacher is qualified to teach.
(C) Any other medium through which a teacher can teach.
7. Personal Identification marks.
8. Academic qualifications in full :

Sr.No Examination Subjects offered Uni. Year of passing Class obtained Distinction ect.
1 2 3 4 5 6 7

9. Professional ( Teaching qualifications in full).

Sr.No Examination Subjects in which the teacher is trained to teach. University Year of passing Class obtained Distinction etc.
1 2 3 4 5 6 7

10. Special qualifications, if any.


Sr.No Examination University Year of passing Class obtained Distinction ect.
1 2 3 4 5 6

11. Signature of the teacher. __________________
12. Signature of the Dead Master / Mead Mistress : ________________________
A Summary of Service.


School Designation Service


from to years

1. 2. 3. 4. 5.










Total Pay
Months Days Pay-scale Starting Closing
6. 7. 8. 9. 10.
Name of the school Date of appointment designation subject thought and standards Whether permanent or probationary or temporary part-times or full time confirmed
1 2 3 4 5

Pay as on 1st June Date of Increment and amount. Allowances
Dearness HRA CLA
6 7 8 9 10

Any other (Indicate the nature) Natures and whether with or without pay. Leave
Duration period
from to month days
11 12 13 14 15 16

Date of Termination of Appointment Remarks, if any (Reasons for termination of service) Date & Signature of
Head of the school Teacher
17 18 19 20