BHARAT ELECTRONICS LIMITED

HUMAN RESOURCES DIVISION

ATTESTATION FORM

Furnishing of false information or suppression of any factual information in the

attestation form would be disqualification and is likely to render the candidate unfit
Add signed passport size from employment under Government / Company.
(5 cms x 7 cm approx.)
copy of recent If detained, convicted, debarred etc. Subsequent to the completion and submission of
photography where asked this form, the details should be communicated immediately to the HR Head,
Corporate Office, Bharat Electronics Limited to whom the attestation form has been
for
sent earlier, failing which it will be deemed to be suppression of factual information.

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 the notice at
any time during the service of a person, his service would be liable to be terminated
without notice.

SURNAME NAME
Name (capitals) with aliases, if any. (Please indicate if you have
1 added or dropped at any stage any part of your name or surname)

Present address in full (i.e. village, Thana and District or House

2 number lane / street / Road and town)

a. House address in full (i.e. village, Thana and District or House

3 number lane / street / Road and town)

b. If originally a resident of Pakistan, Bangladesh, the address in

that country and the date of Migration to Indian union.

Particulars of places (with period of residences) where you have resided for more than ONE year at a time during
4 the preceding 5 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, Name of the District Head

From To Thana and District or House Number Quarters of the place mentioned
Lane / Street / Road and Town) in the preceding column

Page 1 of 5
 Address of your area Police Station with Postal
PIN Code Number

Occupation
(if employed
Nationality Present Postal
give
(by birth Place of address (if Permanent Residential
Name designation
and or by Birth dead, give last address
and full
domicile) address)
official
address)
Father
(name in full with aliases, if
any)

Mother

Wife / Husband

Brother (s)

Sister (s)

5. Information to be furnished with regard to son(s) and daughter (s) in case they are studying in a foreign country.

Country in Date from which

Nationality by
Place of which studying / studying / living in the
Name birth and or by
Birth living with full country mentioned in
domicile)
address the previous column

Page 2 of 5
6 Nationality
(a) Date of birth
7 (b) Present age
(c ) Age of Matriculation
(a) Place of birth, District and State in which situated
8 (b) District and state to which you belong.
(c ) District and state to which your father originally belongs.
(a) Your religion

9 (b) Are you a member of Scheduled Caste / Scheduled Tribe? Answer

'Yes' or No and if the answer is 'Yes' state the name thereof.

Educational qualifications showing places of education with years in Schools and Colleges since 15th
10 year of age.

Name of the School / College Date of

Date of leaving Examination passed
with full Address Entering

11. (a) Are you holding or have any time held an appointment under the Central or State Government or a
Semi-Government or a Quasi Government body or an Autonomous body or a Public Undertaking, or a Private
firm or Institution / If so, give full particulars with dates or employment up to date.
Designation,
Full name and
Emoluments and
Period address of Reasons for leaving previous service
nature of
employer
Employment
From
To

If the previous employment was under the Government of India, a 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 Services) Rules, 1965, or any similar corresponding rules where any disciplinary proceedings are
framed against you, had been called upon to explain our conduct in any matter at the time you gave notice of
termination, actually terminated.

12. (i) Have you ever been arrested? YES / NO

(ii) Have you ever been prosecuted? YES / NO
(iii) Have you ever been under detention? YES / NO
(iv) Have you ever been bound down? YES / NO
(v) Have you ever been fined by Court of Law? YES / NO

Page 3 of 5
 (vi) Have you ever been convicted by Court of Law for any offence? YES / NO

(vii) Have you ever been debarred from any examination or restricted by
YES / NO
any University or any other Educational Institution?

(viii) Have you ever been debarred / disqualified by any Public Service
YES / NO
Commission from appearing at its Examination / Selection?

(ix) Is any case pending against you in any Court of Law at the time of
YES / NO
filling this attestation form?
(x) Is any case pending against you in any University or any other
educational Authority / Institution at the time of filling up this Attestation YES / NO
form?
If the answer of any of the above mentioned question is ‘YES’, the full particulars of the case / arrest /
detention / fine / conviction / sentence / punishment and the nature of the case pending in the court /
University / Educational authority at the time of filling up this form.

NOTE:
Specific answers to each of the questions should be given by striking out ‘YES’ and ‘NO’ as the case may be.

13. Name of two responsible persons of your locality or 1)

two references to who you are known with their full
addresses. 2)

I certify that the following 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 under Government and Government
undertakings.

Signature of candidate Date

Place

Page 4 of 5
 IDENTITY CERTIFICATE
(Certificate to be signed by any one of the following)

i. Gazetted Officer(s) of Central or State Government

ii. Members of Parliament or State Legislature belonging to the Constituency where the candidate or his parent /
guardian is ordinarily resident.
iii. Sub-Divisional Magistrates / Officer
iv. Tahsildars or Naib / Dy. Tahsildars authorised to Exercise Magisterial Powers
v. Principal / Head Master of the recognised 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.

Place Signature

Date Designation or Status and Address

TO BE FILLED BY OFFICE

(i) Name, designation and full address

of the appointing authority

(ii) Post for which the candidate

is being considered

Page 5 of 5