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ATTESTATION FORM
Advt 13/2021-22 Cadre Name Additional PML No
No: Assistant
Engineer(CIVIL)

WARNNIG
1
The Furnishing of false information of suppression of any
Affix signed
factual information in the Attestation From would be
Passport size disqualification, and is likely to render the candidate unfit
(5 cms* 7 cms) for employment under the government.

Of screen
If detained ,arrested prosecuted, bound down, Fines,
Photograph 2
convicted ,debarred, acquitted etc subsequent to the
completion and submission of this form,the details should be
Left Hand Thumb Impression communicated immediately to the authorities to whom the
Attestation Form has been sent early,failing which it will be
( માણપ ચકાસણી વખતે ગેઝેટેડ અિધકારીની
deemed to be a suppression of factual information.
બ માં િનશાન કરવાનું રહેશ.ે )

If ,the fact that false information has been furnished or that

3 there has been suppression of any factual information in the
Attestation Form comes to notice at any time during the
service of a person, his services would be liable to be
terminated.

1 Name in full (in block capitals) with Surname Full Name

aliases . 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, and District. Or House No.
Lane/Street/Road & Town)

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3(a) Home address in full ( i. e village Thana, and
District. Or House No. Lane/Street/Road& Town
and name of District Headquarters

3(b) If originally a resident of Pakistan/Bangladesh(erst

while East Pakistan) the address in fiull country
and the date of migration to Indian Union

4 Adhar Card No. (if available)

5 PAN NO. .(if available )

6 Nationality

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 and State to which your father originally

belong

9 (a) Your Religion

(b) Are you a member of a scheduled Cast/ Scheduled

Tribe/Other Backward Classes (Answer Yes/No.) If
Yes, Provide Details.

10 Particulars of places (with periods of residence) where you have resided for more than one year at a time during
the 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 Name of District Head Quarter or the place mentioned in
village Thana & District or preceding column
House No. Lane/street/Road
& Town

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11 Name in Nationalit Place of birth Occupation if Present postal Permanent
full & y by birth employed give address (if dead vive Home
address
aliases if & by designation & last address)
any domicile Official Address

a) Father

b) Mother

c) Spouse

12 Information to be furnished with regard to son (s) and /or Daughters in case they are studying/living in a
foreign country

Name Natiionality Place of birth Country in which studying/living Date from which studying /living in
by birth & or with full address the country mentioned in the
domicile previous column

13 Educational Qualification showing places of education with years in Schools and collages since 15th year of age

Name of School/Collage (with full address Date of Entering Date of Leaving Examination Passed

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14(a) Are you holding or have any time held an appointment under Central or State Government or a Semi
Government or a Quasi Government body or a public sector Undertaking of a private firm or institution ? If so.
give full particulars with date of employment up –to –date

Period Designation, emoluments & Full name & address of employer Reasons for leaving

Form To nature of employment previous

Service

14(b) If the previous employment was under the Government of India /a State Government /undertaking owned or
controlled by the Government of India or a State Government /and Autonomous body /University /Local Body

If you had left service on a giving a month ‘s notice under rule 5 of the Central Services (Temporary Service)
Rules 1965 , or any similar corresponding rules , were any disciplinary proceedings framed against you, or had
been called upon to explain your conduct in any matter at the time you gave a notice of termination of service ,
or at a subsequent dates (s) before you service actually terminated

15(i) (a) Have you ever been kept under detention ? Yes / No

(b) Have you ever been arrested ? Yes / No

(c ) Have you ever been prosecuted ? Yes / No

( i.e has a charge sheet in a criminal case been filed against you in any
court of Law)

(d) Is any criminal case pending against you in any court of Law at the Yes / No
time or filing up the this attestation form ?

(e) Have you ever been convicted by a court of Law for any Office ? Yes / No

(f) Whether discharged expelled withdrawn from any training institution Yes / No
under the Government or other wise ?

(g) Have you ever been rusticated by any University or any other Yes / No
educational authority /Institution ?

(h) Have you ever been debarred/ disqualified/ by any public service Yes / No
commission/Staff Selection commission for any of its
examination/selection ?

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 (ii) If the answer to any of the above mentioned question is ‘ Yes’ give full particulars of the
case/arrest/detention/fine conviction sentence/ punishment etc and /or the nature of the case pending in
the Court/University/Educational Authority etc at the time of filling up this attestation from

Notes (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’ ‘’No’’ as the case may be

16 Names of two responsible person of your locality or two 1)

references to whom you are known

2)

DECLARATION
I certify that foregoing information is correct and complete to the best my knowledge and belief
I am fully aware that by providing false information or suppressing material information, while filling this form . the
authorities have full right to terminate my appointment letter and I am also liable for appropriate criminal/civil/legal
action as correspondence
I am not aware or any circumstances which might impair my fitness for employment under Government

Signature of Candidate
Date
Place

TO BE FILLED BY OFFICE
( i) Name , Designation and full address of the appointment authority

(ii) Post for which the candidate is being considered

ADVT NO :-13/2021-22

CADRE NAME:- Additional Assistant Engineer (CIVIL)

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