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$il Conrirtion as par'**'2 ANKALF No. 3198 Date 18.04.2016 by Dept cf Persc;nnei Adnrinistrative R*forms and Rajbnasha, Gcv!. of Jhaikhand

Z (,) gIIi,rr.9 r,"r;'art:l;,{ian \iln i; ?iT-T r".ffrd 1.; .oti -,:t.ir-, r;s i; "ir;r;'(' 1..: i';:ie-'.. ,iG dlJ!:*i;l d rrod n uv'" '6ri1;r{Efi'-
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'qqpi rr-; ,tir; i ? (V/hether your tr4other/Father holds local resiclent

t. q'qj qitts qm/fif.J Si 5;T{g"S ti qsflfrq fiff1 .ri
certificateofjharkhand)? dvu=[ q€l Noi--,-l
2. rlr1l3trq.i qw /fudr / ffi mr qq {gltqFr i Sr-i *l (\-tihetherAppiicanl's Mother/Fath*ilAncestors is registereriin Khatiyan of
jharkharrd)? Sivesil n€I Noi]
L a"n =.lrr} qrcr/qf.n -Biiisnppf lcant's lvir:ther/Father Lancies:)? :iiYes l--] ce No i--i
4. fql ?dlg sN-{sr-€ d rqre-a o,reT, q{Efd, !-taI{I * erql-o t? lVtrnetirerApplicant aware of ioeai ianguage. cultrire, tradition of
jharkhand)? dyesi] ,{ *of]^ -Ei\nl
5. gqT .nlq-ffiq alrysT-s{ird qrdrft*c{T tfi-fla d o"{t H? {Wt'retirr:r applicant or his/her MotherlFather at: employee of
jharkhand State Govt.)? d.ves itfo I^€ [-i
6. q;q1 iq11T rqq al?l.rt's1qd qrdTr/ilTT qT-c {T{.nl{op;i t s:.r-l-{!.li;.i -{Tu{r i ,iew$ttr d? lWnetner applicant or hislher
+ ?iffi t
Motheri Father an employee of Central Govt. ancl postecl in Jharkhandl? i'.ii'/e+,; i - -:
qS Nc L.- - ,

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y'#:*trH*ffiiffi:gt?l,?$',i11':n,.TJ;:H,;*,X;* ;rharkhandstate)? dvesi- r ;,*'Nor:
* *r do* *r* tift.U}yrl .roof q-EimeT rd{ *t Xft 1*eir Fiiii-glcrj .fteri i.hfr qi;s'flT srd ln€-{e rt sr(l ihi t?
insiituiir.'r: situateci in
iWhether Applicant heq dogqtgta{*hisiher matriculation 6r equivalent eti,;cation fronr any recognized
Jharkh;rnd)? 6rYes j {6; Noi-
giqlsus q1,rl d F-}qrq oEii si-s +rqe .Elqji' +tffio a"i 'd?
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10. Eqi c{q Eiu c,rE* oind ffi,zi}6r fur-o :o eS t *

(Vlrhether Applicant's or hislher Mother/Father residing in ihe .Jharxhanci State since iast 30 year and heve acquired
imrrrovableproperty)? dvesf] r& no;
t wq gm s)frn 6{dT q fr tt EriT * q€ sq-+ffi 'rg,+r c-S qFlqfle d qrq Si qa"66 zb arurq *} *i i
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i"t ftSq 6IX$ 6Tqqtt C Ui te-fr Eo I (l hereby cieclare that ihe airr:ve mentioned informatisn is true and correct in my
knowledge. lf any of the above information found incorrect, /
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I wiil liable {or legal action as per law') e{fAE-# ?rT E{f,TeN (Appricant's signature)

$elf declaration [l Letter of pledge

Residential Proof
f;lectriuity Bill[j 'Ielephone Bill
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Documents in evidence of claim for local resident i

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