Schedule-17A
(Relating to Sub-rule (1) of Rule 101)

Pension Requisition Form
To,
The Director General,
Civil Employees Record Office.
Whereas, I am going to retire/have retired from the civil service for the
following reason from date……………..,
Now, therefore, I have set out the details relating to my service and necessary
details as follows:
To mention the reason for retirement, mention the mark(×)
(a) Retirement from age limit:
(b)
(c)
I have served for Twenty years or more pursuant to Section 37(1) of the Civil
Service Act, 2049(….). I have, therefore, filled up and sent this form for the
preparation of the pension authorization.
1. Name, surname:
1A.Employee code number:
2. Permanent address (district, VDC/Municipality, as well):
3. Age to complete on the date of retirement: Year ….Month……Day
4. Designation on the date of retirement:
5. Office in service when retired:
6. Office of initial recruitment and date of recruitment:
7. Testamentary heir’s:
(a) Name, surname:
(b) Address (district, VDC/Municipality, as well):
(c) Relation (set out relationship):
Address where the letter of authorization is to be sent by the Civil Employees
Record Office:
Signature:
Date: