To be filled in by the candidate in his own handwriting

No.F/1

/9

-R

Roll No.


(5
..x7 ..) 7?B
% C *
Affix singed Passport size
(5cmx7cm approx.) copy of
recent photograph


/ATTESTATION FORM
/WARNING


    
  
$ %
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.

&  ), *  , , ),

, ., 0
, 2
&  % 4 * 7
&, 
 70 
If detained, arrested, prosecuted, bond down, fined, convicted, debarred, acquitted etc. subsequent to the completion
and 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.

&  ;<2   
     

% = % 
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 services would be liable to be terminated.
/Surname
( ?@ ) @ &
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).

2.

 (
, .,
// )
Present address in full (i.e. Village, Thana and District or
House Number, Lane/Street/Road and Town)

3.

() (
,

()

., // 

)
(a) Home address in full (i.e. Village, Thana and District or
House Number, Lane/Street/Road and Town and name of

(a)

District Headquarter).

()    
  
(b) If originally a resident of Pakistan the address in that
country and the date of migration to Indian Union.

()
(b)

/Name

2
4.

7@ E ( % *@ &) 0 F 
* @ & 0 @ (7

&) @ 7@ E &
* 21
% @
Particulars of places (with periods of residences) 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.

 7@ (
I,

0  & 7 J

From

To

.,  //
)

Residential address in full (i.e. Village, Thana and

Name of the District Headquarters of the

District or House Number, Lane/Street/Road and

place mentioned in the preceding column

Town)

5.

()
(a)

BK

L ()

) 7

; (& 

Relation Name

Place of birth

(&

Permanent

* )

0 )

Home address

Nationality (by

& )

birth

Occupation

and/or

by domicile)

employed

Present
(if
give

designation

full

address

Postal
(if

dead

give last address)

&

Official address)
(i) 0 ( , @
& & ) Father
(Name in full aliases, if
any)
(ii) Mother
(iii) M/ Wife/Husband
(iv) Brother(s)
(v)  Sister(s)
()

0  / N/(N@) / N/(ON@)  C7
% 

(b)

Information to be furnished with regard to son(s) and/or daughter(s) in case they are studying/living in a

foreign country.

L () /

) 7

0  & 

Name

* )

Place of birth

/ P

 / P

Nationality (by birth

Country in which

Date from which

and/or by domicile)

studying/ living with

studying/living in the country

full address

mention in previous column

3
6.

L
Nationality

7.

8.

9.

()

) %  (7  )

()

(a)

Date of birth (in Christian era)

(a)

()

()

(b)

Present Age

(b)

()

&R

()

(c)

Age at matriculation

(c)

()

) 7, S  7

()

(a)

Place of birth, District and State in which situated

(a)

()

 S

()

(b)

District and State to which you belong

(b)

()

0 T  S

()

(c)

District and State to which your father originally belongs

(c)

()

()

(a)

Your religion

(a)

()

U * //) 0  ?  T 

()


(b)

Are you a member of a Scheduled Caste/Scheduled Tribe/OBC? Answer

(b)

Yes or No
10.

15
% - 7@ @  - F  ? C= % 7@ F & ?

$
Educational qualification showing places of education with years in Schools and Colleges since 15th year of age:
7/
Name of School/College with full address

11. ()

C % 

% 

?

Date of entering

Date of leaving

Examination

U )W S
- 7   7 
 X

  X 7 )

P
 ? & , 2 %  &
0 
(a)

Are you holding or have any time held an appointment under the Central or State Government or a semi-Government

or a quasi-Government body or an autonomous body, or a public undertaking or a private firm or institution? If so, give full
particulars with dates of employments up-to-dates:
*

, BE 7T

2

 

Period

Designation, emoluments and nature of

Full name and address of

Reasons of leaving previous

employment

employer

service

From

To

11. ()

U 0 /S /  S 7 4  X,  7

, 0Z0[/7  , & )W 0  (7 ) , 1965  5 )

C @  & U 0T\ 
 % %
= & &  % 7  =  
7] ?
(b)

If the previous employment was under the Government of India/State Government/an Undertaking owned or controlled

by the Govt. of India or a State Government/Autonomous body/University/local body. If you had left service on giving a month
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 your services actually terminated?

4
12.

() U *^  ?

(a) Have you ever been arrested?

/

() U ?

(b) Have you ever been prosecuted?

() U ?

(c) Have you ever been kept under detention?

() U  ?

(d) Have you ever been bound down?

Yes/No
/
Yes/No
/
Yes/No
/
Yes/No
(.) U  0* ) _

(e) Have you ever been fined by a Court of Law?

/

 ?

Yes/No

() U  ) _ P?

/

(f) Have you ever been convicted by a Court of Law for any offence?

Yes/No

() U  ? 0
 0Z0[  ) */7 _

/

 ?
(g) Have you ever been debarred from any examination or rusticated by any University or any other

Yes/No

educational authority/institution?
() U  /
 _ %  ?  /

/

0
/$ P?
(h) Have you ever been debarred/disqualified by any Public Service Commission/Staff Selection Commission

Yes/No

for any of their examination /selection?

() 
U  )  0`\
?

/

(i) If any case pending against you in any court of law at the time of filling up this Attestation Form?

Yes/No

() 
U  b? C*/7  0`\ ?

/

(j) Is any case pending against you in any University or any other educational authority/institution at the time

Yes/No

of filling up this Attestation Form?

() U  C ? 7
2
/c /C4  ) P?

/

(k) Whether discharged/expelled/withdrawn from any training institution under the Govt. or otherwise?

Yes/No

() 2  Cd &  */)/

/// &
/
)/0Z0[/b? C*/7   E

(l) If the answer to any of the above mentioned question is Yes, give full particulars of the
case/arrest/detention/fine/conviction/sentence/punishment etc. and/or the name of the case pending in the
Court/University/Educational Authority etc. at the time of filling up this form.
&e

(1)

Note:


 g
Please also see the Warning at the top of this Attestation Form.

(2)

7  C4 Cd h - & &
Specific answer to each of the question should be given by striking out Yes or No as the case may be.

13.

 ;<2@ ;<2@  @
Name of two responsible persons of your locality or two referees to whom you are known.

1.
2.

P Cg /  

0Z 

P  7 B*
 P  $
I certify that the foregoing 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 Government.

 7?.....................................
Signature of Candidate...............................
..................................
Date
7 .................................
Place

5

-
IDENTITY CERTIFICATE
C-N  g  _ 7?B  Certificate to be signed by any one of the following:(1)

)W S ON *;
Gazetted officers of Central or State Government;

(2)

 -0 / ?  
?N 7 S 0 .
7;
Members of Parliament or State Legislature belonging to the constituency where the candidate or his parent/guardian
ordinarily reside;

(3)

<0 7R /*;
Sub-Divisional Magistrate/Officers;

(4)

7R % <2@ C C* -;
Tehsildar or Naib/Dy. Tehsildar authorized to exercise magisterial powers;

(5)

 )C= 7//7 0C /Jk;

Principal/Headmaster of the recognized School/College/Institution where the candidate studied last;

(6)

E 0 *;
Block Development Officers;

(7)

77;
Postmaster; and

(8)

?;
Panchayat Inspectors;

6
Cg  P l/l/ ................................................................................................................................... N
/N
l
.............................................................................................................. 0 .................................. F .............................. @
0Z  E & P  P
Certified that I have known Shri/Shrimati/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.

7? .............................................................
Signature..........................................................
................................
Designation or Status and address................................
7 ..........................
Place
 .........................
Date
_____________________________________________________________________________________________________________
(
_ )
(To be filled by the office)
(1)

<2 C* ,
Name, designation and full address of the appointing authority

(2)

  0 
Post for which the candidate is being considered.