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Verification Roll: Surname Name

This document is a verification roll used to collect personal information for employment purposes. It requests information such as: 1. The applicant's full name, aliases, present and past addresses, date and place of birth, age, education history, nationality, religion, and references. 2. Employment history including designations, periods of employment, and reasons for leaving past positions. 3. Criminal history disclosures and certifications that all information provided is true to the best of the applicant's knowledge. The form is to be signed by the applicant and certified by a gazetted officer affirming their knowledge of the applicant.

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Soumen Jana
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272 views3 pages

Verification Roll: Surname Name

This document is a verification roll used to collect personal information for employment purposes. It requests information such as: 1. The applicant's full name, aliases, present and past addresses, date and place of birth, age, education history, nationality, religion, and references. 2. Employment history including designations, periods of employment, and reasons for leaving past positions. 3. Criminal history disclosures and certifications that all information provided is true to the best of the applicant's knowledge. The form is to be signed by the applicant and certified by a gazetted officer affirming their knowledge of the applicant.

Uploaded by

Soumen Jana
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Verification Roll

Passport size photograph

1.

Name in Full (In block capitals) with aliases, if any. (Please indicate if you have added or dropped, at any stage, any part of your name or surname). The name of the post and service applied for Present address in full (i.e. village, thana and district or house number, lane/street and road, PIN) (a) Home address in full (i.e. village, thana and district or house number, lane/street and road, PIN) (b) If originally a resident of Pakistan, Bangladesh, Nepal or any other country, the address in that dominion of migration to Indian Union.

Surname

Name

2. 3.

4.

5. Particulars of places where you have resided for more than one year during the preceding five years From To Residential address in full (i.e. village, thana and district or house number, lane/street and road, PIN)

6. (a) Fathers name in full with aliases, if any

(a)

(b) Present Postal address (if dead, give the last address) (b) (c) Permanent home address (d) Profession (e) If in service, give designation and official address 7. (i) Nationality of (a) Father (b) Mother (c) Husband (d) Wife (a) (b) (c) (d) (c) (d) (e)

2 8. (a) Exact date of birth [To be supported by Birth Registration Certificate/Admit Card of West Bengal Board of Secondary Education/any other recognized Board] (b) Present age (c) Age of Matriculation/School Final (a)

(b) (c)

9. (a) Place of birth, district and State in which is situated (b) District and State to which you belong

(a)

(b)

10. (a) State your religion (b) Are you member of scheduled caste/ Scheduled tribe/ OBC. Answer Yes or No and if the answer is Yes state the name thereof. [Copy of certificate to be attached] 11. Education qualifications showing place of education with year in school colleges: Name of school/colleges with full address Date of entering Date of leaving Examination passed

12. If you have at any time been employed give details Designation of the post held or description of work Period Full address of the office, firm or institution and reasons for leaving previous service

13. Have you ever been convicted by a Court of any offence or charge-sheeted by the police in connection with any criminal proceeding? If so, the full particular of the case should be given. 14. Name of two responsible persons of your locality or two referees to whom you are known (1) .. (2) ..

I certify that the foregoing information is correct and complete to the best of my knowledge and belief. I am not aware of my circumstances, which might impair my fairness for employment under Government. I understand that submission of false information will make me ineligible for employment.

Date. Place.

Signature of the candidate

(Certificate to be signed by a gazetted officer)

Certified that I have known Shri/Shrimati son/daughter of Shri.. for the last years months and that to the best of my knowledge and belief the particulars furnished by him/her are correct.

Place. Date.

Signature. Designation status and address .

Signature and designation of the Issuing Officer and the name of the office with full address and date.

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