FROM FOR THE REFUND OF SERVICE CHARGES OF RS.

6000/-

FROM EMIGRANTS WHO PROCEEDED ABROAD FOR EMPLOYMENT

NAME & LICENSE NO. OF O.E.P: M/s. …………………………………………………………

ADDRESS: ………………………………………………………………………………………………...

Sr.No. NameLHR & Father’s Name Passport No F.S.A. No & Date Date & Destination Flight No & Time Ticket No

01 aaaaaaaaaaaaaaaaaaa bbbbbbbbbb 0000 00-01-2000 00-01-2000 LHR-DMM SV735 00436876387761

02 bbbbbbbbbbbbbbbbb cccccccccccc 0000 00-01-2000 00-01-2000 LHR-DMM SV735 00438888005645

03 ccccccccccccccccccccc cccccccccccc 0000 00-01-2000 00-01-2000 LHR-DMM SV735 00562156446466

04 ddddddddddddddddd cccccccccccc 0000 00-01-2000 00-01-2000 LHR-DMM SV735 00585876766611

05 eeeeeeeeeeeeeeeeee cccccccccccc 0000 00-01-2000 00-01-2000 LHR-DMM SV735 06005445464688

CERTIFIED BY THE OVERSEAS EMPLOYMENT PROMOTER

1. I herby certify that the above mentioned emigrants have left for employment abroad,

And have resumed their on the dates specified above.

2. I also undertake that if the above statement is found F.S.A. Signature or incorrect liable

For disciplinary action. SINATURE AND SEAL OF

OVERSEAS EMPLOYMENT PROMOTER