CHECK LIST

(For Joining in AIIMS, Bhubaneswar)

1. Acceptance for joining AIIMS, Bhubaneswar.
2. Character Certificate (Two Gazetted Officer separately) in the prescribed format.
3. Allegiance to the Constitution in the prescribed format.
4. Oath of Secrecy in the prescribed format.
5. Declaration regarding Bigamous Marriage in the prescribed format.
6. Home Town Declaration in the prescribed format.
Declaration on Dependent Family Members in the prescribed format with age proof
7.
copy.
Declaration for OBC in the prescribed format along with valid OBC Certificate within
8.
six months.
9. Undertaking for not tendering Resignation within six months of Joining.
10. Declaration for Spouse is employed in Government Services in the prescribed format.
Declaration of Marital Status from the new entrants to Govt. Service (along with
11.
marriage certificate if married).
12. Employee Data Sheet in the prescribed format.
13. Attestation Form in the prescribed format (Four copies duly filled and attested).
14. Declaration of Characters and Antecedents (in Rs.10/- Stamp Paper).
15. Form for New Pension Scheme (details to be furnished by the Govt. Servant).
16. Undertaking for submission of Factual Information in the prescribed format.
17. Medical Examination Report in the prescribed format.
18. Declaration of Immovable and Movable Property in the prescribed format.
Affidavit on non-judicial Stamp Paper (dully notarized) mentioning that all your
19.
Educational Qualifications and Experiences are from recognised Institutes/College.
20. NOC/Discharge/Relieving Certificate from your previous employer.
21. Self-attested copies of all Educational & Experiences Certificates.

Signature :…………………………..………………
Name :………………..………………………………
Date :………………..………………………………..
 Dated :……/……/…………

To

The Executive Director,

AIIMS, Bhubaneswar

Sub: Submission of acceptance for joining in AIIMS Bhubaneswar.

Dear Sir,

With reference to your Offer of Appointment Letter No.

……………………….......................................dated…………….. for the post of
………………………………………………………………………………………, I hereby
accept the Offer of Appointment and all the terms & condition as contained therein. A set
of self attested certificates of my all qualifications and experiences are also enclosed.

I thank you once again for providing me the opportunity to serve the Institute. I
will join immediately as per the scheduled period given in Offer of Appointment.

Yours sincerely,

Name: ……….………………..……………….

Designation: ...…………………………………..

Date of Birth: ………..………………………...

 CHARACTER CERTIFICATE

I certify that I have known Mr./Ms.……………………………………………………………………

Son/Daughter of Shri……………………………………………..…..……………………………… for the

last………….years ………months. He/She bears a good moral character and is of

………………………….nationality. He/She is not related to me.

Place: Signature: .............………………...............………………..

Date: Name (in Capital Letters) :……………….………………..
Designation & Address:….....………………………………
With Stamp

This certificate should be from any one of the following:

1. Gazetted Officer of Central or State Government;

2. Members of Parliament or State Legislature belonging to the constituency where the candidate or
his parent/guardian is ordinarily resident;
3. Sub-Divisional Magistrates/ Officers;
4. Tehsildars or Naib/ Deputy Tehsildars authorized to exercise magisterial powers;
5. Principal/Head Master of the recognized School/College/Institution where the candidate studied
last;
6. Block Development Officer;
7. Post Masters;
8. Panchayat Inspectors.
 Allegiance to the Constitution

I ……………………………………………., do swear in the name of God/solemnly affirm

that I will bear true faith and allegiance to the Constitution of India as by law established, that I
will uphold the sovereignty and integrity of India, that I will duly and faithfully and to the best of
my ability, knowledge and judgment perform the duties of my office without fear or favour,
affection or ill-will and that I will uphold the Constitution and the Laws.

Signature

Name : ….……………………………………………..

Designation : ………………………………………….

Department : ………………………………………….
 FORM - I

OATH OF SECRECY

I, ………………………………………………………………(name) do
swear/solemnly affirm that I will be faithful and bear true allegiance to India
and to the Constitution of India as by law established, that I will uphold the
sovereignty and integrity of India, and that I will carry out the duties of my
office loyally, honestly, and with impartially. So “Help me God”.

Signature: ……………………….

Name: ……………………………..

Signature of Head of Office

 Date:…………………..

Declaration Regarding Bigamous Marriage

I hereby declare that I have not entered into or contracted a marriage with a
person having a spouse living, or who, having a spouse living, have not entered
into or contracted a marriage with me.

Signature:………………………………………..

Name: ….………………………..………………..

Designation:..……………….……………………

Department:..……………………………………..
 HOME TOWN DECLARATION FORM
[OM No. 43/15/57-Estts. (A) dated 24-6-1958]

I, ___________________________hereby declare that my home town is at the place as shown

below for the purpose of availing Leave Travel Concession for self and family as notified in the Govt. of
India, Ministry of Home Affairs, New Delhi O.M. No.43/1/55/Estts - (A) Part-II dated 11-1-1956.

Home Nearest Rly Station District/Town & State Remarks

Town/Place of
visit

_______________________
Signature

Name : ……………………………………………………………..

Designation : …………………………………………………….

Department : …………………………………………………….

Countersigned by ……………………………………………..

Head of Office
 Date: …………………

Declaration on Dependent Family Members

(1) Personal Details:

1 Name
2. Designation
3. Date of Birth
4 Date of Joining
(2) Details of the Dependent Family Members:

Place mention
the category: Personal
Age
Name(s) of the (a)Employed Annual
Date of as Marital
Sl. member(s) of the Relationship (b)Pensioner Income of
birth on Status
family* (c) Family the
date Pensioner dependent
(d)Others

(*) (i) I hereby undertake to keep the above particulars up-to-date by notifying to the Head of
Office of any addition or alteration.
(ii) Family for this purpose means family as defined in Clause (b) of sub-rule (14) of Rule
54 of the CCS (Pension) Rules,
1972.[http://persmin.gov.in/pension/rules/pencomp7.htm#Family_Pension,_1964]
(iii) Wife and husband shall include respectively judicially separated wife and husband.
(iv) A self-certified proof of Date of Birth is enclosed in respect of dependent
Brothers/Sisters, if any.

Signature of the Employee

(Contd….P/2)
 -:2:-

(3) For the use of Controlling Unit/Office of the HOD Forwarded

Forwarded Recommended

Section/Unit I/C HOD

(4) Administrative Approvals:

Checked Verified &Submitted for Approved as per

approval Rules

Dealing Assistant
Assistant Admin. Officer DD(A)/Director
To

The Executive Director,

AIIMS, Bhubaneswar

DECLARATION
(OBC Candidates only)

I, ………………………………………………………………………………..…….
Son/Daughter of Shri……………..………………… resident of Village/Town/City
……………………… District …………….…….…… State ………….………… hereby
declare that I belong to the …………………….community, which is recognized as a
Backward Class by the Government of India for the purpose of reservation in services as
per orders contained in Department of Personnel and Training Office Memorandum No.
36012/22/93-Estt.(SCT), dated 08.09.1993. It is also declared that I do not belong to
persons/sections (Creamy Layer) mentioned in Column-3 of the Schedule to the above-
referred Office Memorandum, dated 08.09.1993. In case, it is found at any stage that this
declaration is incorrect, then my appointment will be terminated without giving me any
opportunity for representation.

Date:………………………………. Signature of the candidate

Name &Permanent Address

…………………………………..
…………………………………..
…………………………………..
…………………………………..

Note: To be filled only by OBC category candidates

 Date: ………………….

DECLARATION
(If Spouse is employed in Government Service)

I,……………………………………………………………………………….Son/Daughter of
Shri……………..…………………….………………resident of Village/Town/City ……………………District
…………….…….…… State …………..……………………… hereby declare that my spouse is
employed/not employed in Government Service, and she/he is not availing the following facilities for
herself/himself or for any of the family members from the Parent Department/Institute working for. I
read the enclosed provisions made in the Government Orders (printed overleaf) in this regard and
undertake to inform the Institute as and when there is any change in the status of employment of my
spouse in respect of the following conditions.

1) Medical Attendance/Treatment
2) House Building Advance
3) Children’s Educational Assistance
4) Family Planning Special Increment
5) Leave Travel Concession
6) Travelling Allowance
7) Family Pension
8) House Rent Allowance, if residing in Govt. Quarters
9) Central Government Health Scheme
10) Allotment of Residence

The relevant Rules as summarized in the enclosure (appended overleaf) are read and certified
that the same will comply from time to time. I/we understand that any violation will attract legal
proceedings and penal provision as per Govt. Rules.

Signature of Spouse, Signature of

if employed Employee
elsewhere in Govt
establishments
Name : Name :
PF No. : PF No. :
Designation : Designation :
Department : Department :
Address : Address :
 MARITAL DECLARATION
(To be obtained from new entrants to Government Service)

1. I, Shri/Smt./Kumari. __________________________ declare as under :-

(i) That I am unmarried/a widower/a widow.

(ii) That I am married and have only one spouse living.
(iii) That I have entered into or contracted a marriage with a person having a spouse living.
Application for grant of exemption is enclosed.
(iv) That I have entered into and contracted a marriage with another person during the
lifetime of my spouse. Application for grant of exemption is enclosed.

2. I solemnly affirm that the above declaration is true and I understand that in the event of the
declaration being found to be incorrect after my appointment, I shall be liable to be dismissed
from service.

Date : ……………………………..
Signature
 Affix Stamp Size
Photograph
EMPLOYEE DATA SHEET

Name in Full (First Surname)

Married( ) Unmarried( ) Male ( ) Female( )

Mother’s Name (First Surname)

Father’s Name (First Surname)

Present Address (for Communication):

Permanent Address:

E-mail :
Telephone Office:
Residence: Mobile -

Day Month Year

6. Date of Birth

7. Nationality:

(Contd….P/2)
 -:2:-

8. Category: SC ST OBC UR EWS

9. Academic Record starting with Secondary Education:

% of
Branch/ College/University Yea
Examination Marks/ Division
Specialization /Institute r
Grade

10. Professional Experience Record:

Name of Institution/
Position Held Date of Joining Date of Leaving
University

11. Please provide your family details (dependents only)

Present
S.No Name Date of Birth Relationship
occupation

DECLARATION

I, _____________________________________hereby, declare that all entries in this

form are true to the best of my knowledge and belief.

Date: Signature of the employee

 ATTESTATION FORM

WARNING: - The furnishing of false information or suppression of factual information in the Attestation Form
would be a disqualification and is likely to render the candidate unfit for employment under the Government.

2. If detailed, convicted, debarred etc. subsequent to the completion and submission of this Form the
details should be communicated immediately to the Ministry of Health & Family Welfare, Government of India,
New Delhi or the authority to whom the attestation form has been sent earlier, as the case may be 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 suppression of any factual
information on the attestation form comes to notice at any time during the service of a person, his/her service
would be liable to be terminated.

(1) Name in full (in block capitals) with address, SURNAME NAME
if any, please indicate if you have added or
dropped in any stage any part of your name
or surname.
(2) Present address, in full (i.e. Village, Thana &
District or House No., Lane, Street, Road &
Town)
(3) (a) Home Address in Full (i.e. Village, Thana
& District or House No., Lane, Street, Road
Town & name of the District Headquarters.)
(b) If originally a resident of Pakistan the
address in the country and the date of
Migration to Union of India.
4. Particulars of places (with period of residents) where you have resided over more than one year at a
time during the preceding five 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.
From To Residential address in full (i.e. Village, Name of the District
Thana & District or House No., Lane, Headquarters of the place
Street, Road & Town) mentioned in the preceding
Column
 -:2:-

Occupation if
Nationality employed Present Postal
Name in Full (by birth Place of give Permanent Home
5 (a) Address if dead give a
(Aliases, if any) and/or by Birth designation & Address
last address
domicile) official
address
(i) Father

(ii) Mother

(iii) Wife/Husband

(iv) Brothers

(v) Brothers

(vi) Sisters

(vii) Sisters

5. (a) Information to be furnished with regard to son(s) and/or daughter(s) in case they are studying/living in a Foreign Country.
Date from which
Nationality (By Place of Country in which studying with studying/living in the
Name
Birth/domicile) Birth full address country mentioned in
previous column
 -:3:-

6. Nationality of the candidate:

7. (a) Date of Birth :

(b) Present Age :
(c) Age at Matriculation :

8. (a) Place of Birth, District and :

State in which situated
(b) District and State to which :
you belong.
(c) District & State to which
your father originally belong :

9. (a) Your Religion :

(b) Are you a member of a Scheduled
Caste/Scheduled Tribe/OBC
(Please indicate)

10. Educational Qualification showing Places of Education with years in Schools &
Colleges since 15 years of age :

Date of Date of Examination

Name of the School/College with full address
Entering Leaving Passed

(Contd……P/
4)
 -:4:-

11. (a) Are you holding or have any time hold an appointment under the Central Govt. or State
Govt. or a Semi Govt. or a Quasi Govt. Body or an Autonomous Body or a Public
Undertaking with date of employment up to date :

Period Designation,
Emoluments & Full name & address of Reasons for leaving
From To nature of employers previous service
employment

11. (b) If the previous employment was under Govt. of India, a State Govt.,an Under-taking
owned or controlled by the Govt. of India or a State Govt./ an Autonomous
Body/University/Local Body. If you had left service on giving a month’s notice under
Rule 5 of the Central Civil Service (Temporary service) Rules, 1965 or any similarly
corresponding rules were and disciplinary proceedings framed against you or had you
been called up to explain conduct in any matter at the time you gave notice of
termination of service, or at subsequent date, before your service actually terminated?

12.(1)(a) Have you ever been arrested? Yes/No

(b) Have you ever been prosecuted? Yes/No
(c) Have you ever been kept under detention? Yes/No
(d) Have you ever been bound down? Yes/No
(e) Have you ever been fined by a Court of Law? Yes/No
(f) Have you ever been convicted by a Court of Law for any offence? Yes/No
Have you ever been debarred form any Examination or restricted
(g) Yes/No
by any University of any other Educational Authority/Institution.
Have you ever been debarred/disqualified by any Public Service
(h) Yes/No
Commission for any of its Examinations/ Selections?
Is any case pending against you in any Court of Law at the time of
(i) Yes/No
filling up this Attestation Form?
Is any case pending against you in any University or any other
(j) Educational Authority/Institution at the time of filling up this Yes/No
Attestation Form?

(Contd……P/
5)
 -:5:-

12. (2) If the answer to any of the above-mentioned questions is ‘yes’ give full particulars of the
case/arrest/detention/time/conviction/statement/punishment etc. and or the nature
of the case pending in the Court/University/Educational Authority etc. at the time to
filling up this form.

NOTE: (i) Please also see the ‘WARNING’ at the top of this Attestation Form.
(ii) Specific answers to each of the questions should be given by striking out ‘YES’ or ‘NO’ as the
case may be.

13. Name and address of the two responsible 1.

persons at your locality or two residents to
whom you are known

2.

I certify that the foregoing information is correct and complete to the best of my
knowledge and believe. I am not aware of any circumstances which might impair any fitness for
employment under Government.

Place:
Date: Signature of the Candidate
 UNDERTAKING FOR NOT TENDERING RESIGNATION WITHIN 6 MONTHS

I,………………………………………………………………………….
son/Daughter of Mr/Ms…………….…………..………………resident of
Village/Town/City…..……………………District …………….…….…… State
…………..……………………… is hereby undertake that I will not tender
my resignation from the post of.............................................................
within 6 months after joining in AIIMS Bhubaneswar.

Signature

Name :… .…………………………

Date
 DECLARATION FOR CHARACTERS AND ANTECEDENTS
(It should be typed & singed by the candidate in a Rs. 10/- stamp paper duly notarized)

I, Ms/Mr………………………………………………….Son/Daughter/Husband/Wife
of…………………………………………………..………………………….presently residing
at ……………………………………..…………………….…………………………….is
declaring that :-

1. I have not ever been arrested.

2. I have not ever been prosecuted.
3. I have not ever been kept under detention
4. I have not ever been bound down.
5. I have not ever been fined by a Court of Law.
6. I have not ever been convicted by a Court of Law for any offence.
7. I have not ever been debarred from any Examination or restricted by any University
or any other Education Authority/Institution.
8. I have not ever been debarred/disqualified by any Public Service Commission or
Recruitment or any other Examinations/Selection.
9. No case is pending against me in any Court of Law as on date.
10. No case pending against me in any University or any other Educational
Authority/Institution as on date.
11. I have never been discharge/withdrawn from any Training Institution under the Govt.
or otherwise.

Based on the above declaration, I may kindly be issued provisional appointment

order which is pending for verification of character antecedent from the appropriate
authority.

I hereby undertake that in case of anything adverse is found in contradiction to

the above declaration the provisional Offer of appointment may be cancelled without
giving further opportunity.

Date: ………………………………… Signature of the candidate

Name:

Permanent address:…………….
……………………...……………..
……………………………………..
……………………………………..
……………………………………..
 Annexure-I

New Pension Scheme

(Details to be furnished by the Government servant)

Name of the Government servant (in Block Letters) :

Designation :

Name of Ministry/Dept./Organization :

Scale of Pay :

Date of Birth :

Date of joining Government service :

Basic Pay :

Nominee for accumulations the Pension Account :

Percentage Relationship with

Sl.
Name of nominee(s) Age/ Date of Birth of share of the Government
No.
payable servant

Signature of the Government servant

 UNDERTAKING
(For submission of Factual Information)

1. The furnishing of the false information or suppression of factual

information on my joining would be a disqualification and will
render my appointment to be cancelled at any stage.

2. If it has been found that I have furnished false information or that

there has been suppression of any factual information which
come to the notice at any time during my service, my service will
be liable to be terminated.

3. The Degree/Diploma and Experience Certificates as declared by

me in on-line applications are recognised by the University/other
Government regulating agencies. In case, it is found that the
same is not recognised by at any stage, my appointment may be
cancelled.

4. I also declare that I possess all requisite qualification and

experiences as per the requirement of the advertisement and in
case it is found that I am not fulfilling any eligibility criteria, then
my appointment will be treated as cancelled.

Signature with Date

Name :………………………………..…
 MEDICAL FITNESS CERTIFICATE

I hereby certify that I have examined Mr/Ms………………………….........…….. a

candidate for employment in the All India Institute of Medical Sciences (AIIMS), Bhubaneswar
and cannot discover that he/she ………………………………………………..………..(name of the
candidate) has any disease (communicable or otherwise), constitutional weakness or bodily
infirmity except …………………………………………………………………………………………... I
do not consider this a disqualification for employment in the Office of All India Institute of
Medical Sciences (AIIMS).

Signature/Thumb and finger

impressions of the Candidate

Place :
Date : Civil Surgeon/District Medical Officer/
Medical Officer of equivalent status

CANDIDATES’ STATEMENT AND DECLARATION

The candidate must make the statement required below prior to his medical examination
and must sign the declaration appended thereto. His attention is specially directed to the
warning contained in the Note below:-
1. State your name in full (in block letters) ………………………..………………………..
2. State your age and place birth ……….………………………………………...
3. (a) Have you ever had smallpox,
Intermittent or any other fever,
enlargement or suppuration of glands,
Spitting of blood, Asthma, heart disease
Lung disease, fainting attack rheumatism,
appendicitis? …………………………………………………
OR
(b) Any other disease or accident requiring
confinement to bed and medical or
surgical treatment? …………………………………………............
4. When you were last vaccinated? ………………………………………………….
5. Have you or any of your near relations
been afflicted with consumption,
scrofula gout, asthma, fits, epilepsy or
insanity? ………………………………………………….
6. Have you suffered from any form of
nervousness due to overwork or any
other cause? ……….…………………………………………
7. Have you been examined and declared
fit for Government service by a Medical
Officer/Medical Board, within the last
three years? ……….…………………………………………

(Contd.….P/2)
 -:2:-

8. Furnish the following particulars concerning your family:

Father’s age if Father’s age at No. of brothers No. of brothers
living and state of death and cause living, their ages dead, their ages at
health. of death. and state of death and cause
health. of death.

1.
2.
3.

Mother’s age if Mother’s age at No. of sisters No. of sisters

living and state of death and cause living, their ages dead, their ages at
health. of death. and state of death and cause of
health. death.

1.
2.
3.

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

I also solemnly affirm that I have not received disability certificate/pension on

account of any disease or other condition.

Date : Signature/thumb and finger impressions of the candidate

Signed in my presence: …………………………………..

Signature of Medical Officer/District Medical
Officer /Medical Officer of equivalent status

N.B : the candidates shall be held responsible for the accuracy of the above statement. By
wilfully suppressing any information he will incur the risk of losing the appointment and, if
appointed, of forfeiting all claim to superannuation allowance or gratuity.
[M.H. OM No. F.5 (11)-55 MII dated the 27th September, 1957]
Important Note:
B(2)(b): In the case of female candidate appointed to a non-gazetted post (i) in Delhi the
medical certificate shall be signed by an Assistant Surgeon Grade-I (Woman) under the
Contributory Health Service Scheme; and (ii) in any other place by a registered female medical
practitioner possessing a medical qualification included in one of the schedules to the Indian
Medical Council Act, 1956 (102 of 1956) (Indian Medical Central Act, 1970 and Homoeopathy
Central Council Act, 1973).
 RULE 18. MOVABLE, IMMOVABLE AND VALUABLE PROPERTY:

THE SCHEDULE

[See Rule 18 (1)]

Return of Assets and Liabilities on First Appointment on the ____/____/2024

1. Name of the Government servant in full……………………………………………………………………………………….

(in block letters)

2. Service to which he belongs…………………………………………….

3. Total length of service up to date……………………………………….

(i) In non-gazetted rank.

(ii) In gazetted rank.

4. Present post held and place of posting…………………………….

5. Total annual income from all sources during the Calendar year immediately preceding the 1st day of January 20 .

6. Declaration -

I hereby declare that the return enclosed namely, Forms I to V are complete, true and correct as on…………….to the
best of my knowledge and belief, in respect of information due to be furnished by me under the provisions of sub-rule
(1) of rule 18 of the Central Services (Conduct) Rules, 1964.

Date………………….

Signature………………………….

Note-1 : This return shall contain particulars of all assets and liabilities of the Government servant either in his own
name or in the name of any other person.

Note-2 : If a Government servant is a member of Hindu Undivided Family with coparcenaries rights in the properties
of the family either as a ‘Karta’ or as a member, he should indicate in the return in Form No. I the value of
his share in such property and where it is not possible to indicate the exact value of such share, its
approximate value. Suitable explanatory notes may be added wherever necessary.
 FORM NO. I

Statement of immovable property on first appointment as on the ____/____/2024

(e.g. Lands, House, Shops, Other Buildings, etc.)

Sl. No. Description of Precise location Area of land (in Nature of land in Extent of interest If not in own
property (Name of District, case of land and case of landed name, state in
Division, Taluk and buildings) property whose name
Village in which the held and his/her
property is situated relationship, if
and also its any to the
distinctive number, Government
etc.) servant
1 2 3 4 5 6 7

Date of How acquired (whether Value of the Particulars of Total annual Remarks
acquisition by purchase, property (see Note sanction of income from the
mortgage, lease 2 below prescribed authority property
inheritance, gift or if any
otherwise) and name
with details of
person/persons from
whom acquired
(address and
connection of the
Government servant, if
any, with the
person/persons
concerned) Please see
Note 1 below)
8 9 10 11 12 13

Date …………………….

Signature ……………………………….………….

Note (1) For purpose of Column 9, the term “lease” would mean a lease of immovable property from year to year or
for any term exceeding one year or reserving a yearly rent. Where, however, the lease of immovable property is
obtained from a person having official dealings with the Government servant, such a lease should be shown in this
Column irrespective of the term of the lease, whether it is short term or long term, and the periodicity of the payment
of rent.

Note (2) In Column 10 should be shown -

(a) where the property has been acquired by purchase, mortgage or lease, the price or premium paid for such
acquisition;

(b) where it has been acquired by lease, the total annual rent thereof also; and

(c) where the acquisition is by inheritance, gift or exchange, the approximate value of the property so acquired.
 FORM NO. II

Statement of liquid assets on first appointment as on the ____/____/2024

(1) Cash and Bank balance exceeding 3 months’ emoluments.

(2) Deposits, loans, advances and investments (such as shares, securities, debentures, etc.)

Sl. No. Description Name & Address Amount If not in own Annual income Remarks
of Company, name, name and derived
Bank etc. address of
person in whose
name held and
his/her
relationship with
the Government
servant
1 2 3 4 5 6 7

Date …………………….

Signature ………………………….

Note 1. In column 7, particulars regarding sanctions obtained or report made in respect of the various transactions
may be given.

Note 2. The term “emoluments” means the pay and allowances received by the Government servant.
 FORM NO. III

Statement of movable property on first appointment as on the ____/____/2024

Sl. No. Description of items Price or value at If not in own name, How acquired with Remarks
the time of name and address approximate date of
acquisition and/or of the person in acquisition
the total payments whose name and
made upto the date his/her relationship
of return, as the with the
case may be, in Government
case of articles servant
purchased on hire
purchase or
instalment basis
1 2 3 4 5 6

Date ………………….

Signature …………………….……………….

Note 1. In this Form information may be given regarding items like (a) jewellery owned by him (total value); (b) silver
and other precious metals and precious stones owned by him not forming part of jewellery (total value), (c) (i) Motor
Cars (ii) Scooters/Motor Cycles; (iii) refrigerators/air-conditioners, (iv) radios/radiograms/television sets and any other
articles, the value of which individually exceeds Rs. 1,000 (d) value of items of movable property individually worth
less than Rs. 1,000 other than articles of daily use such as cloths, utensils, books, crockery, etc., added together as
lump sum.

Note 2: In column 5, may be indicated whether the property was acquired by purchase, inheritance, gift or otherwise.

Note 3: In column 6, particulars regarding sanction obtained or report made in respect of various transactions may be
given.
 FORM NO. IV

Statement of Provident Fund and Life Insurance Policy on First Appointment as on date____/____/2024

Sl. Policy No. Name of Sum Amount of Type of Closing Contribution Total Remarks (if there
No. and date of Insurance insured annual Provident balance as made is dispute
policy Company date of premium Funds / last subsequently regarding closing
maturity GPF / CPF, reported balance the
(Insurance by the figures according
Policies) Audit / to the
account No. Accounts Government
Officer servant should
along with also be
date of mentioned in this
such column)
balance
1 2 3 4 5 6 7 8 9 10

Date ………………….

Signature …………………………………..…………….
 FORM NO. V

Statement of Debts and Other Liabilities on First Appointment as on ____/____/2024

Sl. No. Amount Name and address of Date of incurring Details of Transaction Remarks
Creditor Liability
1 2 3 4 5 6

Date …………………….

`Signature ……………………….……………….

Note-1 : Individual items of loans not exceeding three months emoluments or Rs. 1,000 whichever is less, need not
be included.

Note-2 : In column 6, information regarding permission, if any, obtained from or report made to the competent
authority may also be given.

Note-3 : The term “emoluments” means pay and allowances received by the Government servant.

Note-4 : The statement should also include various loans and advances available to Government servants like
advance for purchase of conveyance, house building advance, etc. (other than advances of pay and
travelling allowance), advance from the GP Fund and loans on Life Insurance Policies and fixed deposits.
 (Affidavit on Rs.10 Non-Judicial Stamp Paper Duly Notarized)

AFFIDAVIT

I, Mr./Ms. …………………………………aged about ………years, Son/Daughter

of Mr…………………………………………………………………….. resident of
………………………………………………………………………………….……………, do
hereby solemnly affirm and state as under:-

1. That I am the deponent of this affidavit.

2. That I do hereby declare that I am not indulged or doing private practice of any
kind including laboratory, nursing practice & others.
3. That presently I am not working at any other Institutions or Medical College or
Government/Autonomous/Semi Government Organisation. I have been relieved
by the Institution where I was working previously before joining AIIMS
Bhubaneswar.
4. That I possess the essential qualification for the post of Nursing Officer as per
the NORCET-7 Notice No. 82/2024 dated 01.08.2024 of All India Institute of
Medical Sciences, New Delhi.
5. That, I have acquired the essential qualification from the Institute/College/Board,
which is recognized by the Government
6. That I am not drawing any salary/pension from any source other than AIIMS,
Bhubaneswar.
7. That this affidavit is required to be produced before the Executive Director,
AIIMS, Bhubaneswar for necessary action.

That the facts stated above are true to the best of knowledge and belief.

Deponent Deponent

Notary Public