SCRIBE DECLARATION FORM SSO 2018 PRE-EXAM EMPLOYEES STATE INSURANCE CORPORATION PANCHDEEP BHAWAN, C.I.G. MARG, NEW DELHI

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EMPLOYEES STATE INSURANCE CORPORATION PANCHDEEP BHAWAN, C.I.G. MARG, NEW DELHI-110002 Tel. : 011 23219513, www.esic.nic.in NOTICE RECRUITMENT OF SOCIAL SECURITY OFFICER / MANAGER GRADE-II / SUPERINTENDENT 2018 IN ESI CORPORATION The Phase I Preliminary Examination for the Recruitment to the post of Social Security Officer (SSO)/Manager Gr. II/Suptd. - 2018 is scheduled to be held on 3 rd November, 2018. The link for downloading Call Letter for appearing in Phase-I Preliminary Examination is already available on ESIC website. Appended below is Scribe Declaration Form to be submitted by the candidate using Scribe as per guidelines/instructions given in the form on the day of examination i.e. 3 rd November, 2018 at Examination Center. As per Govt. of India, Ministry of Social Justice & Empowerment OM F. No. 34-02/2015-DD-III, dated: 29 th August, 2018 - the candidate should have the discretion of opting for his own scribe/reader/lab assistant or request the Examination Body for the same. These instructions further provide that In case the candidate is allowed to bring his own scribe, the qualification of the scribe should be one step below the qualification of the candidate taking examination. Accordingly, PWD candidates appearing in the above examination are advised that in case they need the assistance of Scribe, they have the discretion of (1) Opting for their Own Scribe or (2) they can make a request (through email/telephone/written application/personal visit) to the ESIC Regional Office of the State in which their Exam. Center is situated for providing Scribe by 29 th October, 2018. The addresses and email ids of the concerned Regional Directors are appended below at Annexure A. Dated: 24-10-2018 Deputy Director (Rectt.)

GUIDELINES REGARDING PERSONS WITH DISABILITIES Those candidates who are visually impaired or affected by cerebral palsy with loco-motor impairment and whose writing speed is affected can use own scribe at own cost during the online examination. In all such cases where a scribe is used, the following rules will apply: * Please ensure you are eligible to use a scribe as per the Government of India rules governing the recruitment of Persons with Disabilities. In case the candidate is allowed to bring his own scribe, the qualification of the scribe should be one step below the qualification of the candidate taking examination. * The candidate will have to arrange his own scribe at his own cost * The scribe can be from any academic discipline. * Both, the candidate as well as the scribe, will have to give a suitable undertaking, in the prescribed format with passport size photograph of the scribe, confirming that the scribe fulfils all the stipulated eligibility criteria for a scribe as mentioned above. Further, in case it later transpires that s/he did not fulfill any of the laid-down eligibility criteria or suppressed material facts, the candidature of the applicant will stand cancelled, irrespective of the result of the examination. * Such candidate who uses a scribe shall be eligible for compensatory time of 20 minutes for every hour of the examination. (Visually Impaired candidates who do not use scribe will also be eligible for compensatory time of 20 minutes for every hour of the examination.) * Visually Impaired candidates under Blind/Low Vision, who use scribe, may skip the non-verbal questions, if any, in Test of Reasoning and questions on Table/Graph, if any, in Test of Numerical Ability. The candidates will be awarded marks for such Section based on the overall average obtained in other Sections of the respective test. Please fill up the DECLARATION and submit along with the call letter.

DECLARATION We, the undersigned, Shri/Smt/Kum. eligible candidate having qualification and Shri/Smt/Kum. eligible writer (Scribe) having qualification for the eligible candidate, do hereby declare that : 1. The scribe is identified by the candidate at his/her own cost and as per own choice. 2. In case it is found that the qualification of the Scribe is not as declared by the candidate and is beyond the qualification of the Candidate, the candidate shall forfeit his right to the post and claims relating thereto. 3. The candidate is blind/low vision or affected by cerebral palsy with loco-motor impairment and his/her writing speed is affected and s/he needs a writer (scribe) as permissible under the Government of India rules governing the recruitment of Physically Challenged persons. 4. As per the rules, the candidate availing services of a scribe is eligible for compensatory time of 20 minutes for every hour of the examination. 5. In view of the importance of the time element and the examination being of a competitive nature, the candidate undertakes to fully satisfy the Medical Officer of the Organization that there was necessity for use of a scribe as his/her writing speed is affected by the disabilities mentioned in Paragraph 1 above. 6. All the above statements made by us are true and correct to the best of our knowledge and belief. We also understand that in case it is detected at any stage of recruitment that we do not fulfill the eligibility norms and/or that the information furnished by us is incorrect/false or that we have suppressed any material fact(s), the candidature of the applicant will stand cancelled, irrespective of the result of the examination. If any of these shortcoming(s) is/are detected even after the candidate's appointment, his/her services are liable to be terminated. In such circumstances, both signatories will be liable to criminal prosecution. Given under our signature: - Signature of the Scribe Signature of the Candidate Registration No: Roll No.: Postal address: Postal address: STD Code:... Phone No STD Code: Phone No [Mob. No., if any.] [Mob. No., if any.] Signature of Invigilator Photograph of the Scribe

ANNEXURE- A Sl. No. Name of the ESIC Region/State for which the candidate is to be admitted in the Online Examination Address & Contact Number of ESIC Regional Director for making request for Scribe Email Id for making request for Scribe 1. Andhra Pradesh 2. Assam (For all North East Regions) 3. Bihar 4. Chhattisgarh 5. 6. Goa Delhi (including Meerut, Noida, Greater Noida, Ghaziabad) 7. Gujarat 8. Haryana 9. Himachal Pradesh 10. Jammu & Kashmir 48-7-32A, ESIC Road, Gunadala, Vijaywada, Andhra Pradesh P.O. BamuniMaidan, Guwahati-781021. Assam. Contact No. 0361-2550357 Belly Road (J. N. Marg), Opp. C.R. Building, Patna-800001 (Bihar). Contact No. 0612-2521928 107, Ram Nagar Road, Kota,Raipur-492010 Chhattisgarh Contact No. 0771-2254589 DDA Complex cum Office, 3 rd & 4 th Floor, Rajendra Place, Rajendra Bhawan, New Delhi 110 008 Contact No.011-25734381,25745044 3rd floor, EDC Plot No. 23, Patto, Panji, Goa-403001 Contact No. 0832-2438870 Ashram Road, Navrang Marg, Ahmedabad-380014 (Gujarat). Contact No. 079-32400501 Sector-16, N.I.T., Faridabad-121002, Haryana Contact No. 0129-2282442 ESIC Regional Office Housing Board, Phase 1, Sai Road, Baddi-173205. Himachal Pradesh Contact No. 01795-245961 Regional Office, 10-B, Radha Bhawan, Shastri Nagar, Jammu 180 004 (J & K). Contact No. 0191-2459682 rd-andhrapradesh@esic.in rd-ap@esic.nic.in rd-assam@esic.in rd-assam@esic.nic.in rd-bihar@esic.in rd-bihar@esic.nic.in rd-cgarh@esic.in rd-cgarh@esic.nic.in rd-delhi@esic.in rd-delhi@esic.nic.in rd-goa@esic.in rd-goa@esic.nic.in rd-gujrat@esic.in rd-gujrat@esic.nic.in rd-haryana@esic.in rd-haryana@esic.nic.in rd-hp@esic.in rd-hp@esic.nic.in rd-jnk@esic.in rd-jnk@esic.nic.in

11. Jharkhand 12. Karnataka 13. Kerala 14. Madhya Pradesh 15. Maharashtra 16. Orissa 17. Puducherry (including examination centre in Port Blair) 18. Punjab 19. Rajasthan 20. Tamil Nadu Regional Office, ESI Hospital Campus, Namkum, Ranchi-834010 (Jharkhand). Contact No. 0651-2261581 No.10, Binnyfields, Binnypet, Bangalore-560023. Karnataka Contact No. 080-26740764 North Swaraj Round, Thrissur 680020 (Kerala) Contact No. 0487-2331241 Nanda Nagar, Indore-452008 Madhya Pradesh. Contact No. 0731-2576452 108, N. M. Joshi Marg, Lower Parel, Mumbai 400013 (Maharashtra) Contact No. 022-61209777 Regional Office, Panchdeep Bhawan, Plot C, Unit IX, Janpath Bhubaneswar-751022 (Orissa). Contact No. 0674-2546380 ESI Corporation Dorr No. 178, 100 Feet Road, (Opp. To Regional Transport Office), Ansari Duraisamy Nagar, Puducherry-605004 Contact No. 0413-2354268 Block No.3, Sector - 19-A, Madhya Marg, Chandigarh-160020. Contact No. 0172-2544126 ESI Corporation Regional Office, Bhawani Singh Marg, Jaipur 302001 (Rajasthan). Contact No. 0141-2385767 143, Sterling Road, Chennai 600034 (Tamil Nadu) Contact No. 044-28279952 rd-jharkhand@esic.in rd-jharkahnd@esic.nic.in rd-karnataka@esic.in rd-karnataka@esic.nic.in rd-kerala@esic.in rd-kerala@esic.nic.in rd-mp@esic.in rd-mp@esic.nic.in rd-maharashtra@esic.in rd-maharashtra@esic.nic.in rd-orissa@esic.in rd-orissa@esic.nic.in rd-pondi@esic.in rd-pondi@esic.nic.in rd-punjab@esic.in rd-punjab@esic.nic.in rd-rajasthan@esic.in rd-rajasthan@esic.nic.in rd-tamilnadu@esic.in rd-tamilnadu@esic.nic.in

21. Telangana 22. Uttar Pradesh 23. Uttarakhand 24. West Bengal 5.9.23, Hill Fort Road, Hyderabad-500463. Andhra Pradesh. Contact No. 040-23234319 Sarvodaya Nagar, Kanpur-208005, Uttar Pradesh. Contact No. 0512-2217957 Prem Nagar, Wing No.4, Shiv Puri, Prem Nagar, Dehradun-248007, Uttrakhand. Contact No. 0135-2771753 5/1, Grant Lane, Kolkata 700012 (West Bengal). Contact No. 033-22259236 rd-telangana@esic.in rd-telangana@esic.nic.in rd-up@esic.in rd-up@esic.nic.in rd-uchal@esic.in rd-uchal@esic.nic.in rd-westbengal@esic.in rd-westbengal@esic.nic.in