ATTESTATION FORM

"WARNING" The Furnishíng of false infor1nation or

suppression of any factual information
in the Attestation Form would be
disqualiflcation, and is likely torender
the candidate unfit for employment
under the Government.

Afix signed passport size (5 cm. X7cm. 2 If detaincd, arrested, prosecuted,

Approx) copy of recent photograph where bound down, fined, convinced,
asked for.
debarred, acquitted etc. subsequent to
the completion and submission of this
form, the details should be
communicated immediately to the
authorities to whom the attestation
form has been sent carly, failing which
it will be deemed to be a suppression
of factual 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 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 SURNAME NAME

aliases, ifany (Please indicate if you
have added or dropped in any stage
any part of your name or surname)

2. Present address in full (i.e. Village,

Thana and District or House No.
Lane/Street/Road and Town.

3. (a) Home Address in full (i.e Village,

Thana, and District or House No.
Lane/StreetRoad and Town and

(b) If Originally a resident of Pakistan,

the address in that country and the
date of migration to Indian Union.
 where you have resided for mnore
4. Particulars of places (with periods, of residences)
five years. In case of stay abroad
than one year at a time during the precedingwhere you have resided for more than
(including Pakistan) particulars of all places given.
one year after attaining the age of21 years, should be
Name ofthe District
From To Residential address in
full (i.e. Village, Thana
Headquarters of the place
and Distt. or house No. mentioned in the preceding
Lane/Street/Road and column)
Town).
5 Present
Permanent
Name Nationality Place Occupation Postal address Home
(by birth &or of birth (if employed Address
by domicile) give designation (ifdead give
& official last address)
address)
() Father
(name in full
aliases, if)
any
() Mother
(tüi) Wife/Husband
(iv) Brother(s)
(v) Sister(s)
5. (a) Information to be furnished with regard tosons(s) and/or daughter(s) in case they are
studying /iving in a foreign country:
Name Nationality (by Place of Country in which Date from which
birth andor by birth studying/living studying/living in the
domicile) with full Address. country mentioned in
previous column.

6 Nationality.
7. (a) Date of birth (a)
Present Age (b)
(C) Age at Matriculation (C)
8. (a) Place ofbirth, District and a)
State in which situated
(b District and State to which you belong.
(C District and State to which your father
originally belong.
9. (a)
Yours religion
(b) Are you a member of a
Scheduled Tribe? AnswerScheduled Caste/
Yes or No'
10
bducational
since \Sth Qualification showing places of education with years in Schools and
years of age. Colleges
Name of SchooVCollege
Date of entering
Examination passed
with full address
Date of leaving

I1. (A) Are you holding or have any time held an appointment under the
Government or a Semi-Government or a Quasi-Government body, orCentral or State
an autonomous
body, or apublic undertaking, or aprivate fin or institution? if so,give full
with dates of employment up-to-date. particulars
Period Designation, emoluments Full name
Frorm To Reasons for
and nature ofemployment and address leaving previous
of employer service.

11. (B) Ifthe previous employment was under the Government of India, aState
an Undetaking owned of controlled by the Government of Government
ndia of a State
Government/ an Autonomous Body/University/ Local Body.
Ifyou had left service on giving a month's notice under the rules 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, your services actually
terminated?
12. (1) (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? Yes/No
() Have you ever been convicted by a Court of Law for any offence? Yes/No
(g) Have you ever been debarred from any examination or rusticated by
any University or any other educational authority/lnstitution ? Yes/No
(h) Have you ever been
debarred/disqualified by any Public Service
Commission/Staff
selection?
Selection Commission for any of its examination/
Yes/No
() Is any case pending against you in any
Court of Law at the time of
filling up this application form?
Yes/No
) Is any case pending against you
any
educational authority/1nstitution at theUniversity
time of
or any other
filling up this
Attestation Form ?
(3) Yes/No
Whether
discharged/expelotherwise?
under the Government or led/withdrawn from any training institution Yes/No
12., If the answer to any of the above
mention question is Yes' give full particulars of the
arrest/detinenttheion/fine-conviction/sentencelpunishment etc. and/or the nature of the case
pending
case
form. CourtUniversity/Educational Authority etc., at the time of filling up this
NOTE: 0 Please also see the
warning at the top of this Attestation Form.
() Specific answers to each of the
'No' as the case may be. questions should be given by striking out 'Yes' or
13 Name of two responsible persons of
your locality or two references to whom
2
you are known.
Icertify that the
and belief. Ian not aware offoregoing information is correct and
any circumstances which might complete to the best of my knowledge
Government. impair my fitness for employment under

Signature of candidate
Date
Place
 IDENTITY CERTIFICATE
(Certificate to be signed by anyone of the following)
) Gazetted Officers of Central or State
Government;
() Members of Parliament or State Legislature belonging to the constituency where the
candidate or his parent/guardian is ordinarily resident;
(t) Sub-Divisional Magistrates/Officers;
(") Tehsildars or Naib/Deputy Tehsildar authorised to exercise magisterial powers;
() Principal/Head Master of the recognised Schoo/College/Institution where the
candidate studied last;
(vi) Block Development Officer; (vi)
Post-Master;
(vii) Panchayat Inspectors.
Certified that I have known Shri/Smt./Kumari Son/
daughter of Sh. for the last years
months and that to the best of my knowledge and belief the particulars furnished by him/her are correct.

Date
Signature

Place
Designation or status and address
TOBEFILLED BY THE OFFICE
Name, designation and full address of the appointing authority. ()
Post for which the candidate is being considered.