Table for broken service
     Name of Teacher with designation: 

     Name of school                                  :

     Date of commencement of continuous service :         

     Details of broken period of service admissible for service weightage

             

Sl.No	Name of school where  served	Period of service   From                     To		Total service   Y            M             D			In days
1
2
3
4
	Total

	Y	M	D
Total broken service
Regular Govt .service
Total

                                                           Undertaking

                                (G.O. (P)NO.7/16/Fin.dtd20.01/2016)

                

   I                                                 here by agree to refund 

excess pay and allowances ,if any ,drawn by me ,in case it 

is found  later ( even if, it is due to erroneous fixation)that 

I have been paid such  excess

                                                                                        

                                              Signature:

                                             Name :

                                                                                  
                                            Designation :  

                                            PEN :         

                                          Office /Dept.

                                            Station:

                                            Date  : 

 Countersignature:                                                                                         

Name:    

Designation:

 Office /Dept.

Station:

Date  :