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Third Party Statutory Declaration

I, _________________________ [Name of Workplace Referee, preferably one step senior to


the applicant] have been employed with ____________________as a
______________________ [Position of the Referee in the Company] from ________________
[Employment start date of the Referee] till date, and am furnishing a reference letter for
___________________ [Name of Applicant] who is working as a ________________________
[Designation of the applicant in the company] with this company from [Date of Employment of
the Applicant] till date.

I can confirm that __________ [Name of the Applicant] carried out the duties and roles
specified in this document at ___________ [Name of the Company] as I was his/her
____________ [Supervisor, Colleague, Manager etc.] who interacted with and witnessed
his/her work on a regular basis throughout the employment.

The task and duties performed by him/her on a day basis are as follows:-

1.

3.

4.

5.

6.

7.

8.

9.

10.

It is declared that the above statement mentioned document is “Signed Before “me on (DATE)
WITNESS 1 WITNESS 2

NAME NAME

PLACE PLACE

TEL. TEL.

EMAIL-ID EMAIL-ID

DATE DATE

SIGNATURE SIGNATURE

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