DECLARATION TO BE FURNISHED BY

THE CENTRAL GOVERNMENT / PUBLIC SECTOR EMPLOYEES

Certified that,
1. I have resigned from _________________________________________________________________
(Name of the Department/Organization)
effective from _______________________________ (copy of relieving order enclosed.)

2. I am retaining lien with ________________________________________________ effective from

(Name of the Department)
from ______________________ for ___________________ years (Orders enclosed).
(Date) (Period)

_____________________________
(Name in Capital Letters)

____________________________
(Signature)

Date : __________________