Self-declaration Certificate for Completion of Journey for Booking of Air Tickets on Government account.
Annexure·1
Self-declaration Certificate for Completion of Journey
(Annexure to O.M. No. 19024/03/2021·E.IV dated 16.06.2022)
1. I (Name of the employee .. .. .. .. .. .. .. .... .. .. .. .. .. .. ... ... .... .. .. .. .... ... .. .. .. .. .. ..... ) hereby declare and
certify that:
2. have actually performed the onward journey from .. .. .. .. .. .. .... .. ... ... .. ... .. .... to
...... ... ... ..... .... .... .. .... .... .... .. on .. ..... .......... ... ... (date) and return journey
from .... .... ... .... .... .. .... .. .. ... ... .. ... .. to ..... .. .... ... .. ... ... ... .. .. .. ... ... on .... .. ... ...... .. . for the purpose of
Tourffraining.
OR
3. I/We have actually performed the onward journey from .... .... .. ... .. ...... ... .... .. .. ... to
...... ... .. ....... ...... ....... ....... ... on .. .... .......... .... ... (date) and return journey
from ..... .......... ... ... .... .. .... .. ....... .. to .. .. ... ... ..... ... ....... ...... ... ..... on .. .. .... .......... for the purpose of
Transfer/LTC/Retirement. The particulars of the self and family members who have performed journey
either with the Government servant or separately are as under :-
Sl.No. Name Age Relationship with Govt. servant
4. In case the above declaration given by me is not found true at any stage, I shall be liable to
disciplinary action under Central Civil Services (Classification, Control and Appeal) Rules, 1965, as
amended from time to time.
(Signature)
Name of the Government servant. .. ... .... .. ...... ... ..... .. .... ... ... .
Designation ..... ... ... ... .... ... ... ... ..... .... .. .
Name of the Ministry/Department.. .... .. .. .. ... ... .. .. .. ... ... ... .. ... ..
To
Admin/Establishment Section
Ministry/Department... .. .. .. .. .. ..
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