Form of application to take up commercial employment withintwo years after retirement.

(See sub-regulation (6) of regulation 4)

1. Name of applicant                                  :

2. Date of retirement                                  :

3. Particulars of posts                                :

    held during the five                               :

    years immediately                                 :

    preceding retirement                             :

Department Post held From To
Pay-scale Rs.

4. Pay and allowance                                 :

    drawn immediately                                :

    before retirement                                   :

5. Retirement benefits –

    (i) if governed by                                    :

    contributory provident                            :

    fund scheme                                           :

(a) amount of the Board’s                    :

ordinary contribution                         :

with interest thereon                          :

(b) amount of the Board’s                    :

special contribution.                           :

(ii) if governed by pension scheme -

(a) amount of pension                         :


(If a part of pension has

been commuted, details

thereof should be


(b) amount of death-cum-                      :

retirement gratuity


6. Particulars of proposed employment –

(a) Name and address of company/     :

co-operative society/firm/

individual employer

(b) Had applicant any dealings            :

with the company/co-operative

society/firm/individual employer

during the period of his

employment under the Board?

If so, the period and nature of

such dealings.

(c) Nature of the position offered         :

(d) Was the position advertised ?         :

If not, how was offer made ?

(e) Duties of the position offered           :

(f) Does the proposed employment      :

involve work of maintaining

liaison or contact with the

offices and employees of the


(g) Remuneration offered                      :

(h) If proposed employment                  :

involves setting up of a

private practice,

particulars thereof

7. Any other information which                     :

    the employee desires to



Place :

Date :

Signature of applicant