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ATTESTATION FORM
:WARNING:
1. The furnishing of false information or suppression of any factual information in the Attestation form would be a disqualification and is likely to render the candidate unfit for employment under the Government. 2. If detained, convicted, debarred, etc., subsequent to the completion & submission of this form, the details should be communicated immediately to the Union Public Service Commission or the authority to whom the attestation form has been sent earlier, as the case may be, failing which it will be deemed to be a suppression of factual information. 3. If the fact that false information has been furnished of that there has been suppression of any factual information in the attestation form comes to notice at any time during the service of a person his service would be liable to be terminated. ----------------------------------------------------------------------------------------------------------------------------

1.

Name in full (in Block Capitals) with aliases, if any please indicate if you SURNAME have added or dropped in any stage -----------------------------------------------------------any part of your name or surname. NAME

---------------------------------------------------------------------------------------------------------------------------2. Present address in full (i.e. Village, Thana & District, or House No. Lane/Street/Road & Town and Name of Distt. Hdqrs.)

---------------------------------------------------------------------------------------------------------------------------3 (a) Home address in full (i.e. Village, Thana & District, or House No. Lane/Street/Road & Town and Name of Distt. Hdqrs)

---------------------------------------------------------------------------------------------------------------------------(b) If originally a resident of Pakistan the address in that country & the date of Migration to India Union.

Contd.2/-

2 4. Particulars of places (with periods of residence) where you have resided for more than one year at time during the preceding five years. In case of stay abroad (including Pakistan) particulars of all places where you have resided for more than one year after attaining the age of 21 years should be given. From To Residential Address in full (i.e. Name of the Distt. Hdqrs, of the Village, Thana & Distt. Or place mentioned in the preceding House No. Lane Street/Road & column. Town.)

5 (a)

Name

Nationality Place of (by birth & Birth or by domicile)

Occupation if employed give designation & official address

Present postal address if dead give last Address

Permanent Home Address

ii

Father (Name in full, Aliases if any) Mother

iii

Wife/ Husband

iv

Brother (s)

Sister (s)

5 (b). Information to be furnished with regard to son (s) & for daughter (s) in cases they are studying/ living in a foreign country:Name Nationality (by Place of Birth Birth & /or by domicile) Country in which studying living with full address. Date from which studying living in the country mentioned in previous col.

Contd.3/-

3 6. 7. (a) (b) (c) 8. (a) Nationality Date of Birth Present Age Age of Matriculation

: : : :

Place of Birth District & : State in which situated District & State to which : you belong Distt. & State to which : your father originally belong Your religion Are you member of a Scheduled Caste/ Scheduled Tribe/ Other Backward Caste/ YES OR NO

(b)

(c)

9. (a) (b)

: :

10. Educational qualification showing places of education with year in Schools & College since 15 years of age. Name of School/College with full Address Date of entering Date of leaving Examination passed

11. (a) Are you holding or have any time hold an appointment under the Central or State Government or Semi Govt., or a Quasi Govt. body, or an autonomous body, or a Public Undertaking, or a private firm or Institution. If so, give full particulars with dates of employment, up-to-date. Period From To Designation Full name & Address Reasons for leaving employments & nature of employer previous service of employment

Contd.4/-

4 11. (b) If the previous employment was under the Govt. of India, a State Govt./ an Undertaking owned or controlled by the Govt. of India or a State Govt./an autonomous body/University Local Body. If you had left service on giving a Months notice under Rule 5 of the Central Civil Services (Temporary Service) Rules, 1965, or any similar corresponding Rules were any disciplinary proceedings framed against you, or had you been called upon to explain your conduct in any matter at the time you gave notice of termination of service, or at a subsequent date, before service actually terminated.

12. (a) (b) (c) (d) (e) (f) (g)

Have you ever been arrested? YES / NO Have you ever been prosecuted? YES / NO Have you ever been kept under detention? YES / NO Have you ever been fined by a Court of Law? YES / NO Have you ever been convicted by a court of law for any offence? YES / NO Have you ever been bound down? YES / NO Have you ever been debarred from any examination or educational YES / NO authority/institution? (h) Have you ever been debarred /disqualified by any Public Service YES / NO Commission for any of its examination/selection? (i) If any case pending against you in any University or any other educational YES / NO authority/Institution at the time of filling up this Attestation Form? (j) If any case pending against you in any court of Law at the time of filling up YES / NO this Attestation Form? If the answer to any of the above mentioned question is YES gives full particulars of (ii) the case/arrest/detention/fine conviction/sentence punishment etc. and/or the nature of the case pending in Court/University/Educational Authority etc. at the time of filling up this Attestation Form.

NOTE: i. ii

Please also see the Warning at the top of this Attestation Form. Specific answer to each of the question should be given by striking out YES or NO as the case may be.

13. Name of two responsible persons of 1. your locality or two references to whom you are known (with full address) 2.

14.

I certify that the foregoing information is correct and complete to the best of my knowledge & belief. I am not aware of any circumstance which might impair my fitness for employment under Government.

Date : Signature of the Candidate. Place : Grade Place of posting.

5 :: IDENTIFICATION FORM:: (Certificate to be signed by any of the following) 1. Gazetted Officers of Central or State Government. 2. Member of Parliament or State Legislative belonging to the constituency where the candidate or his Parent/Guardian is ordinarily residents. 3. Sub-Divisional Magistrate/Officers. 4. Tehsildars or Naib/Deputy Tehsildars authorized to exercise Magisterial Powers. 5. Principals/Head Master of the recognized school/College/Institution where the candidate studied last. 6. Block Development Officers. 7. Post Masters. 8. Panchayat Inspectors.

Certified

that

have

known

Shri/Smt./Kum. of Shri

________________________________ _______________________________

__________________

Son/Daughter

_____________________ for the last _______________ years ______________ months and that to the best of my knowledge and belief the particulars furnished by him/her are correct.

Date : Place :

Signature with stamp Designation or: status and Address.

TO BE FILLED BY THE OFFICE i. Name, designation and full address of the appointing authority.

ii. Post for which the candidate is being considered.

CANDIDATES STATEMENT AND DECLARATION


The candidate must make the statement required below prior to his medical examination and must sign the declaration appended thereto. His attention is specially directed to the warning contained in the Note below:-

1. 2. 3.

State your name in full (in block letters) . State your age and place of birth .

(a) Have you ever had small-pox, Intermittent or any other fever, Enlargement or suppuration of Glands, spitting of blood, Asthma, Heart disease, lung disease, fainting Attacks, rheumatism, appendicitis ? . Or (b) Any other disease or accident Requiring confinement to bed and Medical or surgical treatment ?

. .

4. 5.

When were you last vaccinated ?

Have you or any of your near relations Been afflicted with consumption, scrofula gout, asthma, fits, epilepsy or insanity ? .

6.

Have you suffered from any form of Nervousness due to overwork or any Other cause ?

7.

Have you been examined and declared Unfit for Government Service by a Medical Officer / Medical Board, within The last three years ? .

8.

Furnish the following particulars concerning you family :Fathers age at death and cause of death No. of brothers living, their ages and state of health No. of brothers dead, their ages at death and cause of death.

Fathers age if Living and state Of health

7 ::2::

Mothers age if Living and state Of health

Mothers age at death No. of sisters and cause of death living, their ages and state of health

No. of sisters dead, their ages at death and cause of death.

I declare all the above answers to be, to the best of my belief, true and correct. I also solemnly affirm that I have not received disability certificate / pension on account of any disease or other condition. Candidates Signature ... Signed in my presence Signature of Medical Officer . NOTE.The candidate shall be held responsible for the accuracy of the above statement. By willfully suppressing any information he will incur the risk of losing the appointment and , if appointed, of forfeiting all claim to superannuation allowance or gratuity. [ G.I., M.H., O.M. No. F.5(11)-55-M-II, dated the 27th September, 1957.]

: CERTIFICATE OF CHARACTER:
Certified that I have known Shri/Smt./Kum. _____________ of the Shri last

___________________________________________________

Son/Daughter for

______________________________________________________________

__________ years and ________________ months and that to the best of my knowledge and belief he/she bears reputable character and has no antecedents which render him/her unsuitable for Government employment.

Shri/Smt./Kum.________________________________________________ related to me.

is

not

Place : Date :

* Signature Name

: :

Designation :

(* To be signed by the Gazetted Officer of Central or State Government)

ATTESTED
Place : Date :

@ Signature Name Designation

: : :

(Attesting Authority) (@ To be attested by Stipendiary Ist class Executive Magistrate/District Magistrate or Sub-divisional Magistrate.) NOTE: Two certificates to be signed by two different Gazetted Officers of the Central or State Government attested by Stipendiary Ist class Executive Magistrate/District Magistrate or Sub-Divisional Magistrate.

9 APPENDIX 3 AUTHORITIES EMPOWERED TO ISSUE CASTE CERTIFICATES [G.I., Dept. of Per. & Training O.M. No. 36012/6/88-Estt. (SCT), (SRD.III), dated 1-44-1990.] The under mentioned authorities have been empowered to issue Caste Certificates of verification 1. District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner/Deputy Collector/1st Class stipendiary Magistrate/Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner. 2. Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate. 3. Revenue Officer not below the rank of Tehsildar, 4. Sub-Divisional Officer of the area where the candidate and/or his family normally resides.