VOLUNTARY RETIREMENT / RESIGNATION PERFORMA

1. Name of the Officer/Official : ……………………………………………..

2. HRMS No : ……………………………………………..
3. Designation : ……………………………………………..
4. Date of Birth : ……………………………………………..
5. Father's Name : ……………………………………………..
6. Qualifying service along with a certificate to the effect issued by AO (TA):
: ……………………………………………..
7. Date of entry in the Department : ……………………………………………..
8. (a) Status of Disc/Vigilance clearance: ……………………………………………..
(b) Indicate Currency of punishment, if any:…………………………………………
9. Rule under which the voluntary retirement /resignation is required:
: ……………………………………………..
10. Date from which the voluntary retirement/resignation is requested: …………………
11. Normal date of superannuation : ……………………………………………..
12. Govt. dues if any pending against the officer/official along with certificates issued to
the effect by AO (Cash) concerned: ……………………………………………..
13. Certificate regarding commercial employment after retirement under Rule 10
: ……………………………………………..
14. Status of absorption in BSNL : ……………………………………………..
15. (a) Bond obligation if any : ……………………………………………..
(b) Details of foreign training any undergone: …..……………………………………

…………………………………………
(Signature of Applicant)
Date: ……………………. Designation: ………………………
Place: ……………………. HRMS No: ………………………..
Certified that the above particulars have been verified from the service record of the
applicant.

DA / SSE / SDE (HRD) / A.O

Undertaking
I,…………………………………working as …………submit my undertaking that:-
1. I shall abide by Rule-10 of CCS (Pension) Rules and shall not accept any Govt./Semi
Govt. job within two years of proceeding of voluntary retirement.
2. I am not under any type of bond obligation now from the BSNL.

Date: ……………………. Signature of Applicant