f.

///\'

PROFORMAOF PARTICULARSTO BE SUBMITTED WHILE FORWARDING LETTERSOF RESIGNATION

1. Name of applicant (with qualification) Designation, Institution Stationand District Dateof birth and age a) Date of frrst appointment b) If Temporaryappointment the No. and dateof the G.O. in which the Temporaryappointment was ordered 5. Natureof appointment(Temporary or Regular,If regular,probationer, probationeror permanent approved G.O.No. anddatein which services were regularised may be furnished) Particulars serviceto furnish in of the appended Form-I Dateof resignation letter Reasons resignation for Addressto which communication hasto be sent Whether resignation a sequel the is to ordersof transfers new station to or a sequelto refusalof request for transferIfso the natureofrequest and otherrelevantdetailsmay be

2.

3. 4.

6.

1. 8. 9.

10.

furnished. 11. Whether applicant furnished has the declaration underrule 41 of the General Rulesfor theMadras State andsubordinate services the in appended II. form

t2.

whereis any disciplinaq'' Whether to pending be furnished proceedings; or correspondence Relevant be should quoted. proceedings of thereis anyrecovery Whether moneyduefrom the Government to if candidate so,the details be quotingRelevant furnished if or correspondenceproceedings any has the Whether applicant designed awayfrom while on leaveof stopped dutyif so,from whenandunder Detailsof leave whatcircumstances, etc. mayalsobe for applied granted furnished. a) The dateuptowhich the officer waspaid(i.e.dutypay andleave salary etc.) thereis any claim dueto b) Whether theofficer,if so furnishthe details.

la t1

14.

6.

15.

16.

Whether applicant on inthe is authorised absence ifso from and whatdateandwhether disciplinary proccedings beeninstituted has against him/her.Therelevant correspondenceproceedings or quoted. be should Whether / shehasundergone he any post-graduate degree diploma or course othercourses training. or or purpose Whether the above for he hasgranted studyleavelor other kindsof leave, so,whether if any recovery to be madedetails be has to furnished.

I7 .

Note: TheG.O.NoandDatein which studyleavewas granted alongwith this officereference whichthe in same wascommunicated be mav furnished.

18.

was paid leave a) Whether/he/she salaryduringthe period of study. was givenprior b) Whetherhe/she postingduring studyperiod.

t9.

a Whetherhe hasexecuted bend the makinghimself liable to service for Government a specifiedperiodof yearsafterthe completionof course and if so,whetherthe provisionsof the bond havebeenfulfilled. If not whetherany recoveryof penaltyis due,If so,how much? Detailsto be furnished. The exactdatespecifyingthe (i.e.)forenoon aftemoon or reasons shouldbe which the resignation from therefor. with reasons accepted of The specificrecommendation the forwardingoffice whetherto accept or their resignation not with sufficientreasons.

20.

2T,

SIGNATURE FORWARDING OF AUTHOzuTY. MEDICAL OFFICER CHARGE/ D.H.O./ IN DFW OF CIIO/AS THE CASEMAY BE.

Particulars furnishedfrom item i to 17 are verified and found correct. The resignation with effect from entered the Medical Officer may be accepted by FN/AN. Note: 1. The particularsrequired in column l to 17 may be collectedfrom the Medical Officer concerned. These particularsmay be verified with the statementof service/servicebooks of the Medical Officers and also with the other relevant recordsavailablein the office of the forwarding authority. 2. The Statementof service / servicebook of the Medical Officer may also be forwardedto this office duly completingall entriesbill the dateof relief. p.t.o.

3. The detailsof the amountdue from the Medical Officer MedicaiOfficermay alsobe furnished' APPENDIX OF PARTICULARSOF SERVICES (NAIVTE) DESIGNATION: District

and also due to the

FROM -I

ll{l-o!

Institution

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From To DesiBnation

Remarks

SIGNATURE FORM _II Rules for the MadrasStateand under Rule 41 of the General Declaration Services. Subordinate of to that I am awareof the consequence my resignation my I herebydeclare to as MedicalService referred in in Surgeon the TamilNadu ai appointment Assistant and Services Rulesfor the TamilNaduStateand Subordinate nut. +t of the General by of especially the fact that I shall forfeit not only the servicerendered me in the Government. the under state services post present heldby me but alsomy previous

STATION: DATE :

SIGNATURE,: NAME IN BLOCK LETTERS: DESIGNATION:

shallbe made or for that no request reappointment reposting I herebydeclare later.

SiGNATURE vrm/