SELF DECLARATION
I Miss/Shri/Smt …………….………………..………...…..….. son of /
Daughter of / wife of …………………......................................................
Age ….…..…, Caste ….…….(SC/ST/OBC/SEBC), Sub Caste ………..………….,
of At ……...........…….., Po …….........…....….., P.S …….........….......….,
District ..............................., State: Odisha, PIN:………………….. do hereby
declare that the information given by me in this application form and its
self-attested enclosures
self-attested enclosures is
is true
true to
to the
the best
best of
of my
my knowledge
knowledge and
and that
that the
the
information furnished is exhaustive and I have not suppressed any fact.
information furnished is exhaustive and I have not suppressed any fact.
That I am solely responsible for the accuracy of the declaration and
That I am furnished
information solely responsible
and liablefor for the accuracy
action under of the declaration
section 199 and 200and of
the Indian Penal
information Code(IPC)
furnished in case
and liable for of wrong
action declaration
under section and
199 information.
and 200 of
Also, I am well aware of the fact that the certificate shall be summarily
the Indian Penal Code(IPC) in case of wrong declaration and information.
cancelled and all the benefits availed by me shall be summarily withdrawn
Also,
in caseI of
amwrong
well aware of the
declaration andfact that the certificate shall be summarily
information.
cancelled and all the benefits availed by me shall be summarily withdrawn
in case of wrong declaration and information.
Signature of the Applicant
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