ATTESTATION FORM

Affixsis@ -
(5 crns. X Z cms. Approx.) r _ .:__= ._j_1ry_48l{u!_q'1.
t3rse rnroTmirron oi suppiession
copy of recent photograph :?:.jiii:n1ln.:t of anv
inrormation in the atesration ror*
and is rikely to render the.candidate
r*rJ;r;;;il;i,t,ir,r;
unfir for emproyrnenl
underJhe Government. -

lf oetainedFGsreb pi-oseluted, bound down fined

convicted,
debarred , acquitted erc subseqr"nr
to rhe compretion ancr
submission of this forrn, rhe
detairs shouto be communicareff
immediately to the authorities
t. *n., the Attestation foril' i
l.?:_!.rcn.renr.earty,
failing which n *iri ou deemed
.s_uppression of factlel information.
rrvv to be
rv vv :

rrrse i.ro1m;tio,i
-rrai I

llii:
tl:* Ji:,Jf,
been suppression or ,n/L.ruat
oeenliinisiieo or rhar
lT
attestation form comes to noiice
informrtion inli,i
at any time during the servic:r:
of a pgSqhilser-vLcq! wourd
1
t i Name-.--l_l
in Fuil (in ntock CaG!
be iiabrl ro be terminared

a
i\aqlg I
Surnanre
L Presenl nOO
& Diskict or house No., Lane,
StrteV RoaO
& Town
; a) Homeaddress@
Diskict or house No, Lane, St*.tiiforJi
Town and name of District
4 Aadhar Card No
i PAN No,
Nationality.
(a) | Date of Birth
(b) PresentAge
|
(c) | Age of Matricutation
Fi"lpta;ffi bnh, disrricGnT stajeln whicrr
situated.
Districtano@-
D'skict and state, which your fathei
originally belong.

COrrlO r 2'
 Your Religion
m$t a member of a schedul Ga tel
Vesftb.
I Schedule
vv..vve,- Tribe/
..,--, OBC,
--i:-,.;_
? .,,.--,,11
Ans\I{er :: .-
::: .r_ j_::-"*--

sldence)ruhere you have resided for more than one

(lncluding',lu=l1tl.ll
V*"irt u ti*u'doringihe,preeeding.f,ve years. {n case o!.stay atroad
particutars af all plaier *ti*r* you-have *sidd ,hr msre than ore year attaining the age of
21 vears should be qiYen
ffiTn-tuiiTMffiot tnu oistricr
Ouarter of the
r-rido i
pface I
(i. e. villpge, Thana & District I
irr nouse No / Lane street/ I mentioned in tht i

ryry+ - -..-ir-e-cegtlu.eeltlqln' i

Present
Postal
Oceupation { lt Addre5s
employed, give {i{ dead
11 Place of designation & give last Permanent
Birth official address -1-
'address)
-""- -'- -.''
Hgmq address
Father

Spouse

L- Contd .PB
12 lnformatiot t+ s,on (s)'and /or
studvinq fl ivinq in a foreion country " '
-=-----:from
1 .Date whbh'
I .r-:-r* I ^r...1.,1^aJ liirinn
Country ln whish lstudYingl living in
in tha
the .:
Nationality
by:.birlh' or studying/ fiving lcot*ntrY ment- ioned i

q{.dtry_s_[-11r-U-e-U9!9-P!'
bvdornicile, Place sf Birlh with,full ad
Narne

13 @ showing Placeso{ edu, mtion wtth

since 15h vear o'f age T__-----.
.---
I
Name of schooll college
with fulladdress Date of Datt ici{ le,ay_iryg-
I

i;*---
-J-
!

,1r 1
,il

ti
--1* -
.tl
ll I

i
ointment under thd Central or'S{ate
i + | 1a1 | Rre you holdir rg or have anY tirre h eld t rn appomtrn
a Semi Government 0ra quasi Gove Gdvernment bodY or an autonomous
I I Government o r
firm or institution? if so, give lull
: seetor undertaking t )ra privaler firm
I lbody or Publit
l- loarticularswitt r dates of erPP-loYmqq!- rrP tb date
- Reasons for leavtng
,Designation Fullname & address
o{ employer. previous service
I

l. ernolurnents & nature

I Period of employment. t

From lTo
I

I
I

'tI
I

Contd P ra
 (4)

:
Government of India/ a state Government
--*--3 , ^
Government of India or a State Government /a ,
undertaking o*n*d oicontrolled by the
Autonomous body / University/ Localbody.

lf you had left service on giving 'a month' notice under rule 5 of the Central
Civit
were
Services (Temporary Servic-es) Rules 1965 or any Similar corresponding,rules,
any disciplinary proceedings iramed against you, or had you been called
upon to
.*pt.in you in any matter at thelime you gave notice of termination of service,
"onduct
or at a subsequent dates (s) before your Services ?c!U3!lylgUtrc!e!.-

@sied? : ::
.l tyes/No
irvv'

tW^a I l\ln
es
Have you ever been proseculed
' _ t'on ? i
Y
' :lu
' -
I No
Yes
J I rr^^
HaveyoueVeruee@[iwi---__.----]It|,I"
-"- ---- ltellN/ No Law for anY offence ?
I Yes N
rveEleS-
------'--l .l-'Yg: l
ls any ease pendrng against you in any Court of Law at the time ||
o{
Yes I ttNo

"""'v up
filling --_ Attestation Form: ?: :: :
-r this I

irom anY ining/- I

training/l
Yes l No
veJl I
institution under theGover@
lf the answer to any of the above mentioned question
is -YES' gives {ull particulars of the case/ arrest -j-
detentionl fine/conviction/sentencel punishment etc
and/ or the nature of the case pending in the court I
university leducational authority etc at the time of filling
un this attestation form.
Notes Please also seQ thg. "WARNING"

nouro tiii sr*inFut "YES1-t't'io' ls tne

case mav be

Cootd. P/5
 (s)

knowledgd ano beliet :

;;;;;;j I {o ine Dest ol rny
I

'f arn-ftllly aware that by providing false information or suppressing materiat

i

infbrmation while filling this fonn, the authorities lave full right lo terminate
my appointment :

letter and I am also liable for appropriate criminal/Civil action

i, ,.onr*quence.
I am not aware of any circumstances, which. rnight impair my fitness for
employrnent under Governmenl.

Signature of candidate .-

Date.-

Place:-

TO BEf,ILLED BY THE OFFICE

'. ., ' 'i'

Name, Desigr,ration and full address of lhe appointment authority.

Post for which the candidate is being esnsidered.

 DEPAR.IMENT OF POSTS: INDIA

The candidate must make the statement required below prior to his/her
Medical Examination and must sign the declaration appended thereto. His/her
attention is specially directed to the warning contained in the Note below:-

L Starteyour name in full (in block lettersJ

2. .State your :rge and place ol'birth.
3. [aJ l{ave you ever had srnall pox, intermittent
or any othe. fever, enlargement or suppuration
of glands, spitting cf blood, asthma, heart disease,
lung disease, fainting attacks, rheumatism, appendicitis ?

OR
Ib]Any other disease or accident requiring confinement
to bed and medical or surgical treatment ?
+. When were yon last vaccinated ?
5. Iiave yolr or any of your near relations been
afllicted vrrith consumption, scrofula,gout, asthma,
('it:;, epilepsy, or insanity 7
6. I'lave your suffered from any form of nervousness
ciue to over work or any other cause ?
7. I..lave you lreen examined and declared fit for
(lovernnrent service by a Medical Officer/Medical
Roard within the last three vears ?

Irurnish the following particulars concerning your family:-

Irather''s age ii living Father's agel at death No. ofbrothers No. ofbrothers dead,
and state of health and cause of
c death living, their ages and their ages at death and
state of health cause of death
Mother's age if li'ving I Mother's'age at No. of sisters living, No. of sisters, dead,
and state of hearlth I death and cause of their ages and state their ages at death and
I dearh of health cause of deiath

I deglane th,at all the above answers to be, to the best of my belief, true
and correct. .

l also solemnly affirm that I have not received d isa bi I ity ce rtificate/pension
on account of any disease or other condition.

Candidate's Signature
Signed in my presence
Signature of-Medical Officer.

Note: The candidate shall be held responsibleforthe accuracyof the-above

Statement. By wilfully suppressing any information, he/she will incur
the risk of losing the appointment, and if appointed, or forfeiting all
' claim to superannuation allowance or gratuity.

:
 HEALTH CERTIFICATE
-
-, -
IlrcrebycertifythatIhave'examinedShri/Smt/Ku.
a candiriate for employment in thc Department of Posts and can not discover that
he / she has any disease I communicable or otherwise) - const'rtutional weakness or,
bodily infirmity except

I do not consider this a disqualification for employment in the

Departrnent of Posts . His/her age.-is according to his /her own statement
years and by appearance about years.

Date: Signatureof Civil Surgeon :

Place: Designation:

Signature of the candidate

taken in my presence.

I also declare that I have never been pronounced unfit for Government
employment by a Mcdical Board or any other duly constituted Medical Authority.

Date : Signature of the candidate

l)lace : Name
 ANNIXURE-I ( DECLAMTION)

I do herebY declare that I have read ccs I conductJ Rules-].964 and thoroughly
understood them.

Signature
I do herebY declarc that I have read the Rules of chapter I of P&T Manual vol.lll and
agree to abide bY its tcr-ms.

Signature.

I------------;.------------ declareasunder:-
1. 'l'hat I am marricrl / unmarried/a widower/a widow'
? 'f hat I am nrarriecl ar.rd my husband has no other living wife to the best of
my knowledge.
3. 'fhat I am married aud have only one wife living.
+. That I am marrieci aud have more than one wife living
fot' grant of exemption is enclosedJ'
[Application
tr 'fhat I am married to a person who has already one wife or more living
[Application fol graut of exemption is enclosedJ.
that in
I solemnly aifirnr ll-tztt the above declaration is true and I understand
I shall be
tlie crrcnt of the declaraltion being found to be incorrect after my appointment,
Iiable [or clismissal.

Signature

I harve read 0fficial secret Act-1923 of Govt. of India and will abide
by it'
OATH
I ------------ do swear/solemnly affirm that I will be faithful and bear
that I will
true allegiance to India and to the Constitution of India as by law established,
uphold the Sovereignty and Integrity of India and that I will carry
out the deities of my
office loyally, honestly a'd with impartiality,So heip me God.

Place
Date
Signature

I solemnly affirm that the above cleclaration is true and I

understand that in the event of the
be liable to dismissal.
dcclaration being f,ound to be incorrect after my appointment, I shall
I)ate
Place
Signature.
 ANNEXURE . II
( Agoendix -L FaJfl - 3 (iv) (c) )
.

CHAE*qE,. cq*TlfjefifF ''

,,
. 'u*
'-r .: I

I
Certified that know Shri/Smt/Ku. ,

son/daughtef of Shri
for the last
Years-months and that'to tJre best,of my knowledge and
belief he/she bears reputable character and
has no antecedents which
render him lher unsuitable for Government emplO5mrent"
2. Shri/Smr/Ku is not related to me.

Place- :

Datc

Signature

. Name

Designation

l
I

I
j

I
 ANNEXURE : II

Appendix J.. Para - -3- (iv) (c)

CHARACTER CERTIFICATE

Certified that I know Shri/Smt/Ku.

son/daug,htei of Shri forthe last
Years-months and that to the best of my knowledge and
belief he/she bears reputable character and has no antecedents which
render / her unsuitable for Government ernplo5rment.
him
2. Shri/Smt/Ku. is not related to me.

Place :

Datc

Signature

. Name

Designation