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Certificate to be used by a member of parliament/Member of

Legislative Assembly/ Municipal Councillor or Gazetted officer

(To be attested by issuing


authority with his/her signature
& rubber stamp appearing half
on the certificate and half on
photograph)

I hereby certify that I know Sh./Smt/Kum……


…………………………………………………………………
son/daughter/husband of ……………………………………..and his/her
personal particulars as given below are correct to the best of my
knowledge and belief.

Father's Name / husband’s name

Date of Birth

Residence Address

Details of issues of certificate

Office address with location (Signature)

Office Seal Full Name:


Date: Designation:
Place: Department/Organisation
Identity card No:

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