ANNEXURET ATTESTATION FORM WARNING; ‘The furnishing of false information or ‘tuppression of any factual information in the Attestation Form would be a disqualification, ‘and is likely to render the candidate unfit for employ! amva 2. If detained, areated, prosecuted, bound down tian (5 eax 7 em appx) Subsequent to the completion and submission of this form the details should be communicated immediately to the authorities to whom the attestation form has been sent cay, failing which it will be deemed to be a suppression of factual information. 3. If the fact that false information has been furnished or that there has been suppressioa of any factual information: in the Attestation Form comes to notice at any time during the service of a person his service would be liable to be terminated. Tame in full Gn BLOCK SURNAME AME capitals) with aliases, if any (Please indicate if you have added or dropped in any singe any part of your name or Surmame. = Present Address in fill ic, | Village, Thana and District or House ‘No, LanefStreel Read and Town. 3) Hone Adon ta all Ey Village, Thana and Distt ox House No., Lane/Street/ }) | If originally = resident of Pakistan, the address in that country and the date of migration to Indian Union.4 Particulars of, lnces (with perlods of readence) where you eve renided for more than one Faricnn ti Gusing te preceding five rare am ofstay abroad including Pakitan) Paticulars of all places whero you have raided for more then one year afer attaining the 88 OF 21 your shooldbe given, eae To | Revidentialaddrea tall (re [Namo of the Disret ‘Village, Thana and District or House | Headquarters of the place ‘No, Lane/Stree/ Road and Towa). | mentioned in the yg cohuran, 5. Tame TRaioraliy] Flaws — of] Ocxopaiba (| Present Pool | Permmscat, (bit ox| Best [cape | eldces | Howe les bydonmiia) oe deal give last Sexigaaton & | adres) fiat erm) Father (Name in fall lise if ny) 1) Mother i) Wife! Husband 1) Brother(@) W) Sister @) Contd..3/-..5{8) Information to. be fumished ‘studying/iving in a foreign Name ‘Nationality Place of | birth me a domicile) ‘With regard to sons) and/or deughier(s) In case they ere ‘Country In whieh | Dawe ‘which studying/iving | sudylngfiving in with full address | the country mentioned in previous column. 6 Nationality 2 @ o © & @ ® © . @ &) Date of Binh Fs Present Age ‘Age at Matriculation = Place of bitth, District and - ‘State in which situated District and State to which - you belong District and State to which - you father originally belong Your Religion = Are you membe of a - SC/ST? Answer in Yes or No,Na Coleg wie ey | >= TRaetag —T pa atcamng Raat] GD AS 30% holding or have any tne eld mn appointment under the Central or State celcnmest or semi-govenment oa Quai-Gav body ora attooomone body or a public WeaegAtns O «privite fmm erintatio, fs giv fal parts wht date of ecpleymnt Period) Designation. |Emoluments |Full name @& [Reasons for & naur of address of | leaving Fa To] employment employer | previous service ai 11,0) Ifthe previous employment was under the Government of India, a State Governmentian Underiaking owmed or contolled by the Govemment of ladia or a Sitle Governmentien ‘Autonomous Body/UniversityLocal Body. Tt you had left service on giving a tion's notice under the Rule 5 of the Central Civil Secvies (Temporary Service) Rules, 1965 or any similar corresponding rules were any dlseiplinary Proceedings framed egainst you, or had you been called upon to explain your conduct in any mater at the time you gave notice of temination of service or a bsequent dale before yout serviews actually temineted, aeYes/No ‘No 120) 1) Have you ever been arrested? ¥, b) Have you ever been prosecuted ? Ya/No ¢) Have you ever bee kept under detention? eine 4) Have you ever been bound down ? Yo/No °) Have you ever been fied by # Court of Law ? Yes/No ri 7 D) Have yo ever ben convicted by Court of Law for any ofe% see 12) Have you ever ben debarred from any examination any University orany other educational authority, instituion 7 b) Have you ever teen debarredidisqualified by aay Public! suff Yes/No Saloaton Commision or any of ifexamiation/ selection? ie ) Aries pending aut you say Cont of aw athe tine of yes/No filling up this Attestation Form ? * d ee ace pending against you in any university of any Ot Yes/No fchucational authority institution ot the time of filling WP this Attestation Form? sini Yes/No Whether dschurgedexpeledwithdewa from any RNAS institution under the Government or otherwise ? é 12@) Ifthe answer to any of the above mentioned question ie Yes, give full particulars of the sea detention SaeoonvieGon/enience/ punishment é and nature of the case pending inthe Court/UniversityEducainal autberity ete, ‘tthe time of filling up this form. NOTE() Plesse also see te warning at the top ofthis attestation form. (i) Speciic answer to each of the questions sbould be given by striking out ‘Yes’ or “No! as the case may be, 13, Names of two responsible person of 1. your locality or two references to ‘whom you sre known. 2 sn yt he foi {information is correct and complete to the best of my jedge and belief 1 am aot aware of axy citumstanees which might impai employment under Government. eS ‘Signature of Candidate, Date Place,(ENTITY cearmcare, (Certificate to be signed: ‘by any one of the following) Guelted Ofc of Cental oe Sats Goverment & "Members of Patiament of Sit Leglalaive belonging to the constituancy 4 the candidates or his Parco guardian is ordinarily resident; SX" Sub-Divisional Magistate Oicers: im Tehsldars or NubvDeputy Tesdars muborlzed to exercae magisterial powers; Principal/Head Mater of the recognized schooVeolegefinaittion wher the ‘candidate studied last; Post-Master, vil Panchayat Inspectors, : Certified that Ibave known Sbri‘Sat/Kurae ——____so/daughter of Shri, Torthe Inst__years_months and that tothe bes of my knowledge and belief the particulars fornished by himJher are comes. Date. ‘Signature, Place ‘Designation or status and address TOBE FILLED BY THE OFFICE i, ‘Name, Designation and full address of the appointing authori, ii. Post for which the candidate it being consideredSHARACTER CERTICATE, Certified tht hv known Shr/inu/Kum, ————_owwitortnngstce oe sie or te te 0, ye ‘oaths and that to the bast Of my knowledge and belie he/she bears a reputable charscter ‘and has no antecedents ‘heh render hinv/hier unsuitable for Goverament Employment. Stei/Smn Aum, is not elated tome, poems og is Pinon: Signature SP Date Designation. Office Sump * At least 6 months at the time of signing the certificate,Certified that T have known Shri/Smt/kCum, ———___towwife/daughtor of Shi ———____for the last*, years, ‘months and that to the best of my knowledge and belief he/she bears a reputable character ‘sndhhas no antecedents which render hinvher unsuitable for Government Employment. Shei/Smt/Kum., is notrelated to me. Place. Signature Date Designation Office Stamp * At least 6 months at the time of signing the certificate, PoeerentadANNEXURE-I DECLARATION 10 BE OBTAINED FROM THE NEW ENTRANTS ‘TO GOVERNMENT SERVICE J, Shri/Shrimeti/Kumay, declares as under, that Tam onmanied/a widower/ «widow fi) dat Tam manitd and have only one spouse living ‘ii) that Thave entered into or contracted « mazriage with a person having a spouse living. Application for grant of exemption is enclosed. x WV) That [have entered into nid contracted a manage with mother person during the lifetime of my spouse. Application for grant of exemption is enclosed, 2 Teoleranly affirm hatte above declarations tue and understand that inthe event of the “cleraton being found to be incorrect afier my appointment, I shall be Table to be dismissed from service. DATE ‘SIGNATURE * Please delete clause/clauscs not applicable,