Locker Surrender Application

To,
________________
______________ Branch

Locker Surrender/Discharge Certificate

I/we hereby certify that I/we have this day withdrawn all the property belonging to us, stored in locker number _______, key bearing number ____ leased on _______, and that the locker and its key are hereby surrendered in token of termination of the lease.

Place:
Date:

(Name & Signature of hirer/s)