FORMAT OF ACCEPTANCE OF OFFER OF APPOINTMENT

I, …………………………………………………………………………………

Son/Daughter/Wife of ………………………………………………………………. do hereby

accept the offer of appointment to the post of ……………………… in Navodaya

Vidyalaya Samiti at JNV ………………………………………………….. District

……………………. State ………………………………….made vide letter No.

……………………….... dated …………………………… I will join duty at the place of

posting on the date mentioned therein without seeking any extension in joining time.

Signature ……………………………

Name ……………………………..……

Address ………………………..………

……………………………………

……………………………………

Dated :

Copy submitted to Deputy Commissioner, Navodaya Vidyalaya Samiti (Regional

Office),

Signature of Candidate: ……………………………

1
 NAVODAYA VIDYALAYA SAMITI
(MINISTRY OF HUMAN RESOURCE DEVELOPMENT)

ATTESTATION FORM

“WARNING”

1. The furnishing of false information or suppression of

Affix signed any factual information in the Attestation Form would
passport (5cm
be a disqualification, and is likely to render the
x 7 cm.
candidate unfit for employment under the Government.
Approx.)
copy of recent
2. If detained, arrested, prosecuted, bound down, fined
photograph
convicted, debarred, acquitted, etc. subsequent to the
authorities to whom the attestation form has been sent
early, failing which it will be deemed to be a
supersession 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 SURNAME NAME

with aliases, if any, [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, and District or
House No., Lane/Street/
Road and Town)

3.[a] Home address in full (i.e.

Village and District or
House No. Lane/Street/
Road and Town and Name
of District Headquarters

[b] If originally a resident of

Pakistan/Bangladesh
(erstwhile East Pakistan)

2
 the address in that country
and the date of migration
to Indian Union.

4. Particulars of places (with periods of residents) where you have resided for more
than one year at a time during the proceeding 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,

and District of H.No.Lane/Street/Road
From To and Town

5. Name Nationality Place Occupation(if Present Permanent

(by birth & of employed give Postal Home
or by Birth designation & Address address
domicile) official (if dead,
address) give last
address)
i. Father
(Name in
full and
aliases, if
any)
ii. Mother

iii. Wife/
Husband

iv.
Brother(s)

v. Sister(s)

3
5. (a) information to be furnished with regard to son(s) and daughter(s) in case they
are studying/living in a foreign country:

6. Nationality :
Name Nationality Place of Country in Date from which
(by birth & birth which studying/ living
or by studying/living in the country
domicile) with full mentioned in
address previous column

7. (a) Date of birth (a)

(b) Present Age (b)

(c) Age of Matriculation (c)

8. (a) Place of Birth, (a)

District and State in
which situated
(b) District and State to (b)
which you belong.

(c) District and State to (c)

which your father
originally belongs.

9. (a) Your religion (a)

(b) Are you a member of (b)

a OBC/Scheduled
Caste/Scheduled
Tribe?
Answer ‘Yes’ or ‘No’.

4
10. Education Qualification showing places of education with years in schools and
colleges since 15th year of age.

Name of the School/ Date Year of passing the % of Marks

College with full Exam
address Entering Leaving

11.a Are you holding or have any time held an appointment under the Central Govt. or
State Govt. or Semi-Govt. or a Quasi Govt. 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 & address Reasons for leaving

From To emoluments of Employer previous Service
and nature of
employment

5
11.b If the previous employment was under the Government of India/State Government/
an Undertaking owned or controlled by the Government of India or a State
Government/ An Autonomous Body/ University/ Local body.

If you had left services on giving a month’s notice under Rule-5 of the Central
Civil Services (Temporary service) Rules, 1969 or any similar corresponding rules
where 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 (i) (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

(f) Have you ever been convicted by a Court of Law for any offence? Yes/ No

(g) Have you ever been debarred from any examination Yes/ No
or rusticated by any University or any other educational
authority/ Institution?
(h) Have you ever been debarred/ disqualified by any Yes/ No
Public service commission/Staff Selection Commission
for any or its examination/selection?
(i) Is any case pending against you in any court of Law at Yes/ No
the time of filling up this Attestation form?
(j) Is any case pending against you in any University or Yes/ No
any other educational authority/ Institution at the time
of filling up this Attestation Form?
(k) Whether discharged/expelled/withdrawn from any Yes/ No
training institution under the Government or otherwise?

6
 (ii) (a) If the answer to any one of the above mentioned question is ‘Yes’ give full
particulars of the case/arrest/detention/fine/ conviction
/sentence/punishment, etc. and/or the nature of the case pending in the
Court/University/Educational Authority etc. at the time of filling of this form.

NOTE: i). Please also see the “Warning at the top of this Attestation Form”.

ii) Specific answers to each of the questions should be given by striking

out ‘Yes’ or ‘No’ as the case may be.

13. Name of two responsible persons of 1

your locality or two references to
whom you are known.
2

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 in the Samiti.

…………………..………….

Signature of Candidate

Date: ……………………

7
 IDENTITY CERTIFICATE

(Certificate to be signed by any one of the following)

i) Gazetted Officers of Central or State Government:

ii) Members of Parliament or State Legislature belonging to guardians is
ordinarily resident.
iii) Sub-divisional Magistrates/Officers:
iv) Tehsildars or Naib/Deputy Tehsildars authorized to exercise magistrarial
powers.
v) Principal/Head Master of the recognized school/ College/ Institution where
the candidate
studied last.
vi) Block Development Officer:
vii) Post Masters.
viii) Panchayat Inspectors.

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.

Date: …………….

Place: …………… ………………………………...

Signature of the candidate

(Designation on status & address)

TO BE FILLED BY THE OFFICE

i) Name, Designation and full address 1

of the appointing authority.

ii) Post for which the candidate is being 2

considered.

8
 CANDIDATES STATEMENT AND DECLARATION

The candidate must take the statement required below prior to his medical examination
and must sign the declaration appended there to. His attention is specially directed to the
warning contained in the note below :

1. Post for which the candidate is being

considered.

2. State your name in full (in block letters)

(a)State your age and place of birth

(b) Have you ever had small pox,

intermittent or any other fever
enlargement or suppuration of glands,
spitting of blood, asthma, heart disease,
lung disease, fainting attacks
3. rheumatism, appendicitis?

OR

(b) Any other disease or accident recurring

confinement to bed and medical or
surgical treatment?

4. When were you last vaccinated?

Have you or any of your near relations

5. been afflicted with consumption, scrofula,
gout, asthma, fits, epilepsy or insanity?
Have you been examined and declared
6. unfit for Government service by a Medical
Officer/Medical Board within the last
three years?
Have you suffered from any forms of
7. nervousness due to over work or any other
cause?

8. Furnish the following particulars

concerning your family:

9
Father’s age, if Father’s age at death No. of brothers No. of brothers dead,
living and state of and cause of death living their ages their ages at death and
health and state of health cause of death

Mother’s age, if Mother’s age at No. of sisters living No. of sisters dead, their
living and state of death and cause of their ages and state ages at death and cause
health death of health of death

I declare all the above answers to be, to the best of my belief, true and correct. I
also solemnly affirm that I have not received a disability certificate pension on account
of any disease or other condition.

………………………..
Candidate’s Signature

Date :
Name: …………..……………………..

Designation : …………………………

Signed in my presence ………………………….

Signature of Civil Surgeon or

Medical Officer of equal rank

NOTE: The candidate will be held responsible for the accuracy of the above statement.
By willfully suppressing any information, he will incur the risk of losing the
appointment and if appointed, or forfeiting all claims to superannuation allowance or
gratuity.

10
 MEDICAL CERTIFICATE

1. Name of the candidate : ………………………………………………..

for appointment(in Block letter)

2. Caste or Race : ………………………………………………..

3. Residence : ………………………………………………..

4. Father’s name & Address : ………………………………………………..

………………………………………….…….

………………………………………………..

5. Date of Birth in Christian era : ………………………………………………..

6. Exact height be measurement : ………………………………………………..

7. Personal marks of identification : ………………………………………………..

8. Signature of the candidate : ………………………………………………..

I do hereby certify that I have examined Shri/Smt/Kum………………………………….

a candidate for employment in Navodaya Vidyalaya Samiti and cannot discover that
he/she has any disease communicable or otherwise constitutional affliction or bodily
infirmity except …………………………………………………………………………………………

I do not consider this a disqualification for employment in Navodaya Vidyalaya

Samiti. His/her age is according to his/her own statement ……………… and he/she
appears about …………………. years.

Left hand thumb and finger impression of the candidate.

Signature of the candidate : ………………………………………………..……

Taken before me : ……………………………………………………..

Name of the Officer : ……………………………………………………..

Designation of the Officer (This officer should be Civil Surgeon or Medical Officer or
equal rank ……………………………………. on (date) ……………………………..

Signature of the Medical Officer

Seal

11
 DECLARATION

1. Shri/Smt/Kum. …………………………………………………………………………………
Declares as under:

a) * That I am unmarried/a widower/widow.

b) * That I am married and have only one spouse living

c) * That I am married and have more than one spouse living.

(Application for grant of exemption is enclosed)

d) * That I am married and that during the life time of my spouse, I have
contracted another marriage. Application for grant of exemption is enclosed.
e) * That I am married and my husband has no other living wife, to the best of
my knowledge.
f) * That I have contracted a marriage with a person who has already one wife
or more living. Application for grant of exemption is enclosed.

2. ** I solemnly affirm that the above declaration is true and I understand

that in the event of the declaration being found to be incorrect after any
appointment. I shall be liable to be dismissed from service.

Date : ……………. Signature : ………………………….

Name : ………………………….

Designation : ………………………….

* Delete clauses not applicable.

**Applicable in thy case of clauses (a), (b) & (c) only.

12
 DECLARATION

In terms of Sub Para 4 of Para 1 of the Ministry of Home affairs Office

Memorandum No.43/I/55-Estt-(A)-Part-II date the 11th October, 1956

I hereby declare that my Home Town for purpose of Leave Travel Concession will

be as follows:

I further declare that I fulfill the conditions mentioned in the Ministry of Home

Affairs Office Memorandum No.43/15/57-Estts (A) dated the 24th June, 1958 for the

purpose of declaring the HomeTown.

Date : …………………………… Signature : ……………………………….

Place : …………………………. Name : ……………………………….

Designation : ……………………………….

13
 OATH OF ALLEGIANCE

I, …………………………………………………….. do swear /solemnly affirm that I

will be faithful and bear true allegiance to India and to the Constitution of India as by

the law established, that I will uphold the sovereignty and integrity of India, and that

I will carry the duties of my office loyally, honestly and with impartially.

( So help me God)

Date : …………………….. Signature : ……………………………

Name : ……………………………

Designation : ……………………………

14
 DETAILS OF FAMILY

Name of the Government servant : ……………………………………………………..

Designation : …………………………..…………………………

Date of Birth : ……………………………………………………..

Date of appointment : ……………………………………………………..

Details of the members of my family as on : ……………………………………………………..

Sr. Names of the Date of Relationship Initials of the Remarks

No. members of family Birth with the officer Head of Officer

I hereby undertake to keep the above particulars up to date by notifying to the

head of office any addition of alteration.

Date : …………………….. Signature: …………………………………

Place : …………………….

Family for this purpose means – family as defined in clause (b) of sub-rule (14) of rule
54 of the Central Civil Services (Pensions) Rules, 1972.

15
 Annexure

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES

APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA

The is to certify that Shri/Smt/Kumari, …………………………..…………….

son/daughter of …………………………………………………………………. of village/town
………………………………… in District/Division ………………………………………………...
in the State/Union Territory ……………………………………………….. belongs to the
…………………………………… community which is recognized as a backward class
under the Government of India, Ministry of Social Justice and Empowerment’s
Resolution No …………………………………………………… dated ………………….*.
Shri/Smt/Kumari …………………………….. and/or his/her family ordinarily reside(s)
in the ………………………………………………………… District/Division of the
…………………………………………….. state/Union Territory. This is also to certify that
he/she does not belong to the persons/sections (Creamy Layer) mentioned in Column
3 of the Schedule to the Government of India.
Department of Personnel & Training O.M.No. 36012/22/93–Estt. (SCT) dated
8.9.1993**.

District Magistrate
Deputy Commissioner, etc.
Dated:

Seal

*. The authority issuing the certificate may have to mention the details of Resolution of
Government of India, in which the caste of the candidate is mentioned as OBC.
**-. As amended from time to time.
Note :- The term “Ordinarily” used here will have the same meaning as in Section 20 of
the Representation of the People Act, 1950,.

16
 Annexure-IV

Nomination for benefits under the Navodaya Vidyalaya Samiti Employees

Group Savings Linked Insurance Scheme, 1991. (When the Employee has a
family and wishes to nominate one member or more than one member
thereof)

I …………………………………………………………….. hereby nominate the person(s)

mentioned below, who is/are member(s) of my family, and confer on him/them the right
to receive to the extent specified below any amount that may be sanctioned by the
Navodaya Vidyalaya Samiti under the NVS Employee Group Savings Linked Insurance
Scheme 1991 in the event of my death while in service or which having become payable
on my attaining the age of superannuation may remain unpaid at my death.

the right of the

relationship of
Name, address
with employee

nominee shall
Contingencies

any, to whom
the person, if
happening of

predeceasing
amount to be

the employee
shall become
Relationship
Addresses of

paid to each

event of his
nomination

pass in the
Name and

nominees.

which the
nominee/

Share of

invalid.
on the

and
Age

1 2 3 4 5 6

N.B.: The Employee should draw line across the blank space below his last entry
to prevent insertion of any names after he has signed.

Dated this ……………… day of ……………..19……………………….at …………………….

Signature of two witnesses:

1. …………………………..
2. …………………………..
3.
Signature of Govt. Servant: …………………

This columns should be filled in so as to cover the whole amount that may be
payable under the Insurance Scheme.

17
 Annexure-V

Nomination for benefits under the Navodaya Vidyalaya Samiti Employees

Group Savings Linked Insurance Scheme, 1991.

(When the Employee has no family and wishes to nominate one person or more than
one person)

I, ……………………………………………………………... having no family, hereby nominate

the person/persons mentioned below and confer on him/ them the right to receive to the

extent specified below any amount that may be sanctioned by the Navodaya Vidyalaya

Samiti, under the NVS Employees Group Savings Linked Insurance Scheme 1991 in the

event of my death while in service or which having become payable on my attending the

age of superannuation may remain unpaid at my death.

the right of the

relationship of
Name, address
with employee

nominee shall
Contingencies

any, to whom
the person, if
happening of

predeceasing
amount to be

the employee
shall become
Relationship
Addresses of

paid to each

event of his
nomination

pass in the
Name and

nominees.

which the
nominee/

Share of

invalid.
on the

and
Age

1 2 3 4 5 6

Dated this ……………… day of ……………..19……………………….at …………

Signature of two witnesses:

1. …………………………..

2. …………………………..

Signature of Govt. Servant:

N.B. The Employee should draw line across the blank space below his last entry to prevent
the insertion any names after he has signed.

*This columns should be filled in so as to cover the whole amount that may be
payable under the Insurance Scheme.

**Where a Government servant who has no family makes a nomination, he shall

specify in this column that the nomination shall become invalid in the event of his
subsequently acquiring a family.

18
 UNDERTAKING

I, Shri/Mrs./Ms_________________________________________________________ resident of

_______________________________________________________(full address) hereby solemnly affirm

that no FIR or any court case (Criminal/civil) is registered/pending against me. If statement/information

furnished by me proves to be false or found to have wilfully suppressed any material information, I will

be liable to be removed from the services besides such other action as Samiti may deem fit.

Signature of Candidate: _________________________

Name: ______________________________________

Date:____________

Place:____________