1

u l
,

SSC j o

*.

' INDIVIDUAL'S DECLARATION FORM TO BE SUBMITTED BY

CONTRACTOR FOR OBTAINING C&A VERIFICATION FROM POLXCE

Village:
Police Station :
District :
Contact No., if any:

during last 5 years

1~

9.

I
,

I Certified that he/she is a

Pin -.-.-

Contact No., if any:

-- .-- ---.-

Taluka: -. -.-

--Contact No., if any:

--- -

I
I

I /

COMMENTS :-

Place

--

Pin-.

Character and Antecedent Certificate by Police Authority:

;~bte

--

Village:
Police Station :
District :

ith Address

Pin

Taluka:

Police Station :
D~strict.

Permanent Address

_-

Village:

Taluka:

Signature of police
Authority with Seal

- * , - .
%

0'

11 . 1r

ssc 10

Appendix-llb) of Annexure-I11

INDIVIDUAL'S DECLARATION FORM TO BE SUBMITTED BY

CONTRACTOR FOR OBTAINING C8aA VEFUFICATION F R O M POLICE

'

Taluka:

during last 5 years

Police Station :
I

'Jaluka:

..

--

---

rtified that he/she is a

I
!
l

COMMENTS :-

~---- -..- ,

.'

. ' <. .
.:

,-.

.
- .

_ \

"'

Signature of Police
Authority with Seal