ATTESTATION FORM
WARNING
1. Furnishing of false information or suppression of any
Affix recent (not more factual information in this Attestation Form would be a
than 3 months old & disqualification and is likely to render the candidate unfit
full face coverage) for employment under the Government.
passport size 7cm x
5cm photograph 2. If detained, convicted, debarred etc. subsequent to
(colour) duly attested the completion and submission of this form, the details
by anyone signing should be communicated immediately to the authority to
the Identity whom the Attestation Form has been submitted earlier
Certificate at the end failing which, it will be deemed to be suppression of factual
of Attestation Form. information.
3. If the fact that false information has been furnished or
that there has been suppression of any factual information
in the Attestation Form comes to the notice at any time
during the services of person, his/her services would be
liable to be terminated.
1. Name in full (in BLOCK letters) (Name to
be as mentioned in matriculation certificate
or if changed subsequently to be as
mentioned in the Gazette Notification)
2. Present address in full (i.e. Village, Thana,
District and State or House
No./Lane/Street/Road, Area, Town, District
and State) (Pin Code to be included)
3. (a) Permanent address in full (i.e. Village,
Thana, District and State or House
No./Lane/Street/Road, Area, Town, District
and State) (Pin Code to be included)
3. (b) If originally a resident of Pakistan,
theaddress, date of migration to Indian
Union
Contd….2/-
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4. Particulars of places (with period) or residence where you have resided for more than one year at a 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.
Residential address in full (i.e. Village, Thana,
Name of the District Headquarters of place
From To District and State or House No./Lane/Street/ Road,
mentioned in the preceding column.
Area, Town and State) (Pin code to be included)
Contd….3/-
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5. Family members Particulars:-
Place of Birth
(Mention name Occupation (If Present Postal
Name
Nationality
of place, employed, give address (If dead, Permanent
(by Birth or designation and give last address
district and
by Domicile) official address) address)
state)
(a) Father (Name
in full)
(b) Mother (Name
in full)
(c) Wife/Husband
(if married)
(d) Children (if
any including
adopted)
(e) Brother(s)
(f) Sister(s)
Contd….4/-
-4-
6. Information to be furnished with regard to son(s) and/or daughter(s) in case they are
studying / living in a foreign country.
Date from which
Nationality (by Country in which
studying/living in the
birth & or by Place of Birth studying/living with
country mentioned in
domicile) full address
previous column.
7. Details of the candidate:-
(a) Nationality
(b) Date of Birth
(c) Present Age
(d) Age at Matriculation
Place of Birth, District and State
(e)
in which you were born
District & State to which you
(f) belong
District & State to which your
(g)
father originally belongs
(h) Your Religion
Are you a member of Schedule
Tribe? Answer ‘Yes’ or ‘No’ and if
(i)
the answer is Yes’, State the name
thereof.
Are you a member of Schedule
Caste? Answer ‘Yes’ or ‘No’ and if
(j)
the answer is Yes’, State the name
thereof.
Contd….5/-
-5-
8. Educational qualifications showing places of education with years in school and college
from Class IX onwards.
Name of School/ Examination
Date of entering Date of leaving
College Passed
9. (a) Are you holding or have you any time held an appointment under the Central or
State Govt. or Quasi permanent 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 Designation, Full name and
emoluments and address of employer Reasons for
From To nature of leaving service
employment
(b) If the previous employment was under the Govt. of India/ State Govt./an
undertaking owned or controlled by the Govt. of India or State Govt., an Autonomous
body, University, Local body and if you had left the service on giving a month’s notice
under Rule5 of the Central Civil Services Temporary Service Rule 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/ actually terminated? Yes/ No
10. (a) Have you ever been arrested? Yes/ No
(b) Have you ever been prosecuted? Yes/ No
(c) Have you ever been kept under detention? Yes/ No
(d) Have you ever been bound down? Yes/ No
(e) Have you ever been fined by a Court of
Law for any offence? Yes/ No
Contd….6/-
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(f) Have you ever been debarred from any examination or rusticated
by any University or any other educational authority/ institution? Yes/ No
(g) Have you ever been debarred/disqualified by any Public
Service Commission from appearing at its examination/ selection? Yes/ No
(h) Is any case pending against you in any Court of Law at
the time of filling up of this Attestation Form? Yes/ No
(i) Is any case pending against you in any University or any
other educational authority/ Institution at the time of filling up
of this Attestation Form? Yes/ No
If the answer to any of the mentioned questions is ‘Yes’ give particulars of the
case/detention/fine/conviction/sentence/punishment etc., and/ or the nature, the case pending
in the court/university/educational authority, etc., at the time of filling up of this form. The
details may be provided in a separate sheet which is to be attached to this form.
Note:
(1) Please also see the WARNING at the top of this Attestation Form.
(2) Specific answer to each of the question should be given by neatly striking out
‘Yes’ or ‘No’ as the case may be.
11. Name and addresses of two responsible persons of your locality or two references
(no blood relations) to whom you are known:-
Name Designation/ Address Known for how
Post/Occupation many years
I certify that the above mentioned information is correct and complete to the best of my
knowledge and belief. I am not aware of any circumstances which might impair my fitness for
employment under the Government of India.
Signature of Candidate
Place :
Date : Contd….7/-
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IDENTITY CERTIFICATE
(Certificate to be signed by any one of the following)
(i) Gazetted Officer Group ‘A’ of Central or State Government.
(ii) Member of Parliament or Member of State Legislature belonging to the constituency
where the candidate or his/her parents/guardians is originally resident.
(iii) Sub-Divisional Magistrate/Officers.
(iv) Tahsildars or Naib/Deputy Tahsildars authorized to exercise Magisterial powers.
(v) Principal/Headmaster of the recognised College/School (Institution where the
candidate studied last. If the candidate has passed out of school/ College more than 5 years
ago, the certificate is to be signed by any of the other mentioned here)
(vi) Block Development Officers where originally resident
(vii) Panchayat Inspectors where originally resident
(viii) Post Master where originally resident
Certified that I have known Shri/Smt/Kumari 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.
Signature :
Name :
Post/ Designation :
Address :
Place :
Date :
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
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