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(Attach a Copy)
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Experience in Departmental Enquiry:
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Additional Certilica telExPerieIlce/Awards:


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I declare that all the information fumished by me in my application is true & correct to the best
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ln case, at any stage of the empanelment process or afterwards it is found that
information/certificate given by me is false or fabricated/manipulated or I do not fulfil the
eligibility criteria in terms of advertisement, my candidahlre may be rejected and Company will
be free to take appropriate action against me as per rules. / ecdrotx9- dodr Oeadld oc+ &€o.grJsil
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