Ne S005 Romain a2 aaa - 1 mae ANNEXURE~1 G.a13F fran 66 : Revieed 66 wrens wr ATTESTATION FORM ror = ete lt ee ee ei rt fea me Bra A ee ar sire aera Fe Warning The furshing o false ntrmation or suparession of any factual information in he Atestaton ‘rm would bea disqualification, ands Bikey to rendr th candidat unt for employment under he Gover 2 met art att rete sateen nee nH St gH en fee ne Bk ree et eo secre abn afer rt vet ee AAR sf RE re oe te re edhe ah Bs If detained. convicted, debarred etc. subsequent 0 the completion and submission of this tom. the detals should be communicated immediately tothe Urion Pubic Commission or the away Senvice Commis: ‘Son othe Author to whom te attestation form has been sent earl, asthe case may be fang whicn wi ‘be deemed tobe & suppression of factual information, 2. taht tr ech ate mete oo ae em ere eh He Fh oS stat de sor tt | If te fact that fale information has been fumished or that thre has been suppression of any factus! Information inthe attestation form comes fo notice at ary time during the service of person, hisher service ‘would be lable to be torminates. 1 qiae (ae oats) Fe me wae = = [Name in ul in Block Capitals) with aliases, any — Name pr rd ft awe ee ge an pw stg ee » (Please indicate i you have added or cropped at ary stage {any part of your name or surname) ae ge Ce a, ae et TT, store Present address in fl (\e. Vilage, Thana and Dstict or House Number, Lane(StreetRoad and Town.) 3.) ee (rs, ae ae Pe FE, Tt ‘sya a rere oe TT TH) (8) Home address nfl (e. Vilage, Thana and Dstt or _|- House Number, Lane/StreelRoad and Town andname of District Head Quarters) (8) hearer ny Pera a ro ae see oe a == sate (0) I oFiginaly resident of Pakistan, the address intne | ‘Country and the date of migration to Indian sonsree (oben sn) 2 a eB ee time duing he preceding tne years. Incase 0 stay abead(ncudng Pakistan Youhave fesde for mor than ove yoar ator atanngte age of 21 years sho ern ser ee a tf Particulars of paces with pevods of resi 2 cos where youha ie mt ee resided for more han one yeas at Npartcuars ofa paces where hide er Foe a Ra ee a a ™ am same aes ene “Gress ote ace Fem ee eecage mane ana’ | “mentioned a he ‘Bet ortiome Na pocding Colum. Canned ‘Tour © o co) o wo @ ©) o © @ o Fen iFather's — ‘poe se af, oh Name in fall with aliases, any setae a rn (fa ew fd) Present postal adios Sea, t ss) Permanent Home Adsress Profession sa a cen te meee in serie, give designation and oficial assess. ‘TH Natonaliy of: — en Father Mother trot Husbanarwite Candidate ‘et ae Place af bith of Husband’Wite7 7 are [ay Dateot Ban | @ (om) ba | (0) Presentage | ©, © (6) fem aterm So bs (@)_ Place of bith, Ost and Staten which suatod | (a) (01) fron ate ra fa ot oy (b) District and Sate 6) sre at (% (a) Your Region @ (3) eg ky so de see & at tee a a a bk oo (b) Are you a member of a Scheduled Caste Scho} (@) ‘led’ Tribe ? "Answer "Yes. or No" andi the answer is Yes’ state the name threo eae 1S hay et ae a fs eth ty as Etdvcational Qualications showing paces of education wih yoars i Schools and Colleges sinco 15th saw creme men me | nee ome were aE Teams | base = TT SES On pc aS pcaemeeg sx eseee|icratead a ees = 7 inet a ee eee pete Pe amet | eee instasion prewous service4 1 on) fe far ste seer ra ewe ee Spee at eg me eee FS seen nee (8) IF he previous employment was under the Govern ‘ment of Indla/a State Governmenv/an undertaking ‘ned or contraied by the Government of india or & ‘Sate Govemment/an Autonomous Body/a Univers) {8 Local Body ae ee tr ere e149 an ee te (ove) Fr 1965 & fe § meh fe ody ame sae et she a ya ge ere a eet are sree hgh we He eet TE Sree sit seers rind eh ret ed ae ara ere 7 I you hadi service on givining the requisite period ‘of notice under Rule 149 of he Indian Ralway Estab lishment Code or Rule § of the Cental Civil Servicos (Temporary Service) Ales "1965" or any similar cor responding Rules, were any siscipinary Proceedings ‘ramad against you, or had you been called upen to fxplain_your conduct in any mater atthe time you {gave notice of termination of service, or at a subse ‘Quent date, before your services actually terminated. 12m) er sree wt ow nee fe ee rte ger rae ay em fe arr ee {Ba re ref cbr an ee a wn “eh arn A @ fey fr ver othe se rer et ies fem fh tre sere fee ‘ahr tek ar fe 1? (0) Have you ever been arrested, prosecuted, kept under (©) Is any case pending against you inary Court of Law. Universty or any ather Edueational Authory/instu- tion atthe time of filing this attestation frm ? | 6) eC ake a Sr TC a 8 ae fee Femme sae fe eet ee Fr re ce Spee, ee a, re (©) the answer to (a) o 2) is Yes ful particulars ofthe ‘aso, atest dotention, fine, conviction, sentence eto {and the nature ofthe case pending inthe CourvUn- versity Educational Authoiy tc. at the time of filing ‘Up thi form, shouldbe given oo — ane se eh eo Note Please also see the Waming) at the top ofthis attestation form.eA eh Wa est lard an ae an @ [Names and adaresses ol wo responsible persons of your locality or we elerences to whom you ar known 2 an wre fet et eh arr te fifo ee ghee hed tone an “= "certty thatthe foregoing Informations is correct and complato tothe best of my knowedge and betel am not aware of any circumstances which might ipa my nese for employment under Governor in 0 @ ‘eam Date Signature of Conaidate ar Piaca_ oper aT IDENTITY CERTIFICATE rte 3 8 ht crete ce mT eB CCorticate tobe signed by any one ofthe folowing = (0) eke rm wre wk orc ae Gazetted Oficers of Contal or State Government (aera fry wr eee ‘Members of Parliament of State Legislature, (i) sr teertBaege aoe Sub-Divisional Magistrates/Oticors (i) meee armen mre fe Sree ae we wa we ee se | ‘Tehsidars of Naiy/Deputy Tehsidars Authorised to exeriee magiatral powers, (o) hme taf fara Fe se oe oe ee sen PPhnipals and Head Masters o ll recognise institution including Primary School (ui) ar fra aft Block Dovelopmant Ofice. (vi) ePIR/Post-Mastors, (wi, tee fre Panchayat Inspectors, sar wa fir 8 ot — an ph arse a se ae me 8 a ae ae fe en Certified that have known Sh/ShrimatKuma, a " _years son/daughter of Shi tumished by him/her are correct, ‘eyPlace - er Signature feats) ate—________ ‘wera a sec ae Designation or Salus and Address. (cee gm) (Tobe filed by the office) 1 mse ae ge Namo, dsignton antl adress of en mee A “The Auhory which conducts the vricaton, and 3. shee ee re A set aunon “The Authority to whom te reports have to be sent by he District Aortes = 4. og rer tt ter a Ps ar we wl Pa ' the Railway Fo oar wich caret ple an wich ten cons Ray On ee eee a geionting Acthoriy.