0% found this document useful (0 votes)
364 views24 pagesAttestation Form
AttestationForm
Uploaded by
Rajesh KumarCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
0% found this document useful (0 votes)
364 views24 pagesAttestation Form
AttestationForm
Uploaded by
Rajesh KumarCopyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
/ 24
KOLKATA-2018
aaah
CONFIDENTIAL
PRIORITY
rperie
Roll No.
yer_siatera
ara & a, aR
MINISTRY OF DEFENCE Sara wT BRT
OFFICE OF THE DGAFMS viet rv
ies sa Affix signed passport
‘ATTESTATION FORM easel Fece
FOR DETAILED VERIFICATION photograph
WARNING
1
‘euegies pri A crete year Sar seater freA Ay sears aqua wi Arar Pekar ell atte sell wt, eae tore
3 fay aaa See VIET
‘The furnishing of false information or suppression of any factual information in the Attestation Form would be a
disqualification and is likely to render the candidate unfit for employment under the Government.
aft, ee or a aA ote we Wel Beary staede fre ore &, ehh secre Grr @, gor ore 8 ah ere ati
eons wares Ser faPcer dar AEP Ay srerar we sone wt ARI week eTeafarT wre so var &, oe oA
Raft eh, wh Aor ong, ert wer oe eT OTC fp meme, OTe (er) wy fat Tar 81
If detained, convicted, debarred, etc. subsequent to the completion and submission of this form, the details should
be communicated immediately in the Directorate General Armed Forces Medical Services or authority to whom
the attestation form has been Sent earlier, as the case may be, falling which it will be deemed to be a suppression
of factual information,
aR Pet mater A Ger a ches ae vey ae A maior Ml A er ENT ey mf & er foe Te
carrot) (qgaen) a} Burar var 8, sea Gary were ae eh OMe
Ifthe fact that false information has been furnished or that there has been suppression of any factual information
inthe aestaion orm comes fo notice at anytime during the sevice ofa person is senices woud be Habe to
3@ terminal
“sir [Surname =i /Name
gr am @S seat A) ot ata, aR NE at
Name in full (in capital letters) with aliases if any
Gre ara a wee A ahh EE vst & a a Pa
ea aA ETT 2)
(Please indicate if you have added or dropped at
Any stage any part of your name or sumame)
cada gr wet (sete a, oar wd Pear aterar wer
Fer. FA / BC/BS, SMe TST sie APT FIs)
Present address in full (ie. Vilage, Thana_and
District or House Number, Lane/Street/Road, Town
and PIN Code)
ae rT cer, (a, are, err oh foe terar we
Her sa(ahe/ ee ake cron, Far yee
ar, fy wre)
Home address in ful (Le. Village, Thana and District
or House Number, Lane/Streel/Road and Town,
name of the District Headquarters, PIN Code)
CONFIDENTIAL 4. ay wort ar athe Pare ah oat wie) 2 wel
feet a cet Fmd A a eh wrt wr ate
fare far eh
Particulars of places (with periods of residences)
2
CONFIDENTIAL
caret figs ta are # oa ay Hye at 8 afte aaa fy Pre fer 8)
Fea one et real 9,20 ado org a Gee Go a A a eo @
the preceding five years. In case of stay abroad particulars of all places where the candidate has resided for
more than one year after attaining the age of 21, should be given
) where you have resided for more than one year at a time during
Fa ar ot We wer Galt a arr
ate fore
Rie ator W eaiy ay ea
great wert eo, | a ror Gea wr at
= 3 / Ble / the aft ere, FR ts) Name “of the District
big Residential address in full (ie. Village, | Headquarter of the place
Fron To Thana and District or House Number, | mentioned in the preceding
Lane/Street/Road and Town, name of the | column
District Headquarters, PIN Code)
5. (6) oan a ater
4a) Detals of family: r
t waa GR | aaa sie aT | wad we a wT
= fee é at | vege ye | | Pomanent
eye | aan | SITE | ah allt wer 8) | home address
wt Shasta) | ent | St traf a1 | Present postal
‘aa Relation wa fered) address
Name Natonaity | Pacoot | Tra) | adoss
{eypinh | Birth | employed give | last address)
andlor by Gesignation &
oficial address
i 2 z a 3 é T
Raat GT a
sr a
wig &)
Father Name |
in full aliases,
ifany
at
Mother
Te
| Wite/
Husband 3
CONFIDENTIAL
arg Giga)
Brother(s)
wea (ae)
Sisters)
|
(e) sg (ga) ate /ararar A GPa) A aT hore oH Ae A omar aw HE EY frame we ee E
(©) __ Information to be furnished with regards to son(s) and/or daughter(s) in case they are studying/ ving in forefgn
counity:-
a Whe GA) wae [waite www | hed ean Tae
| Name Ro / sear! Place of bith | at set ref sera | are Ser 4 Fr Fat
siftare Ere) ae 8 E/ Pare ae | 8 sera ae
Nationality (by 8 & Country in wei
birth and/or by which studying/living | Date from which
domicile with full address ~ | studyingflving the
country mentioned
ive in previous column
7 2 z 4 5
|
6. asian
Nationality
7 (@) orm fae
(a) Date of Birth.
(@) ater ang
(0) Present age.
(9) Ager /tarst wae Wie eo} a ory
(0) Age at Matriculation’Sécondary School Certilicate Exam.
8) wr ar were, fran ste ea
{a) Place of birth, District and State,
(@) fron ste wea or ar ford ona &
() District and State to which you belong.
(2) a fore, ste wou aor rm Fore omgeh fa yet wo Beeler &
(c) District and State to which your father originally belongs.
9. ‘i/Religion. 4
CONFIDENTIAL
10, err art we cert ea gel at cat Ee 1s wf A sry a ea atk TSH A we ew onfenst a wher 2
Educational qualifications showing places of education, with years in School and Colleges since 15" year of age
address
Was we eas SR ait wT aT
Name of Schoo/College with ful
BET Tote a ie
Date of entry_| Date of leaving
ane @ mg wer
Examination passed
1. @)
(a)
eat om x REO seraT ero TY steaT PreAond—areeret ar ef ara eee Fara an Poe ware
Fagin oe & serar af Pra we et EP aft te @, oh
an appointment under the Central or State Government or a Semi-
Government or Quasi-Government body, of an autonomous body or a public undertaking, private firm or
institution? If 50, give full particulars with
Frere ar fire ote Samp, wdc WH aT Tee F
srereret (rat a) AREY
‘Are you holding or have any time held
‘ae aor Prati (RFT) 1 IT
dates of employment up-to-date.
‘aaRy Period
8 From
we To
eam ora a Pais Ralee wr Wr a
te ga
Designation, emoluments | Full name and
(ror), a wept
recht Ber (tte) wis?
‘mr wIRUT Reasons for
leaving previous service
2
and nature of employment __| address of employer
3 4
=
|
1
11¢@@) mer Fre Preyer seer
ROR / TH
Pert
ROR / FATT
(b) I¥ the previous employment
was under the Govt. of India/a
State Govt/
‘autonomous body
University/Local body. If you
hhad left service on giving a
‘month's notice, under rule 5 of
the Central
(Temporary
1965. or
Civil Services
Service) Rule,
any similar
rules, where
proceeding
ry
framed against you, or had you
been called
up to explain your
conduct in any matter at the
time you
jave notice of
termination of services, or at a
subsequent
date, before
service, actually terminated? 5
CONFIDENTIAL
().
fe peat eee er ee a see Sea
(a)
Have you ever been arrested? Yes/No Have you ever been Yes/No
prosecuted?
() am ovat anh soRae farm en? B/G) RM OM a ToS BT
(c) Have you ever been kept under Yes/No “Sra fora aa? YesiNo
detention? (Have you ever boon
bound down?
© aig ae Fgh sarees Amy! (e) RT aM He aE M/s
‘wrrar B? Yes/No feral amxra 3 tery Yes/No
(©) Have you ever been fined by a ererat rat &?
Court of Law? () Have you ever been
convicted by a Court of
Law for any offence?
(@) FH saver fet way Gero et/aet(H) a saTey te gle WaT I /aet
Ha, 1, Mg, Rear at Yeo art 3 See aT YésiNo
fet ora Mie sre, ‘arene feat
Te eR aval | eter wea/a Af wer
(eReabe foe) ara? mayor efter frat
(9) Have you ever been debarred a
from any examination or (nh) Have you ever been.
tusticated by any University or debarred/sisquaitied by
any other educational any Public Service
authority/institution? Commission from
appearing at its,
examination/selection?
Fae were or ot a/R O) A ET WENT GM w/e
wa aw si Pee foe YesiNo ARG, Wee Tee BE Yes/No
saraera # aig are affect 8? fost fxaftarea/
(Is any case pending against you Be gerar fret_ ore
in Court of Law at the fimo of Bite ate / er
filing up this ‘Attestation Form’? Yoong arg aaa 8?
(i) Is any case pending
against you in any.
Iniversity or any other
Educational
Authorty/institution at
the time of filing yp tris
‘Attestation Form’
Q ww SIRT WET A
IP the answer to any of the
above mentioned question is
‘Yes. give full particular of the
caselarrest/detention/ —_fine/
‘conviction
sentence/punishment etc.
andlor the nature of the case
en
ding in e
our/University/ "Educational
Authority etc, at the time of
is ‘Form’ 6
CONFIDENTIAL
NOTE (1) rar ge areuion ork Fai we A ag Mor wt af a
Please also see the ‘WARNING’ at the top of this Attestation Form.
(2) ete we at gene ge over AEF AN aA aT ah, BY aTeaR Reem oT)
Specific answer to each of the question should be given by striking out
"Yes' or No’ as the case may be.
13. oh Ie, (ers) 8 a a Pen eared ae feet
seer SS afta aT ey GA sa GTA eT)
Name of two responsible persons of your locality a
Or two references to whom you are known
@
8 seni oar & PO ag gale are AR fears ay oRgER ae ote EE BL AS BN RE RReaaat
BH ore ae & Gt awEN Gra ) By AA sugar w fey ero et
1 erty thatthe foregoing information is correct and complete tothe best of my knowledge and belief. | am not
‘aware of any circumstances which might impair my fitness for employment under Government.
spat & ERT
‘Signature of candidate,
fees
Date.
rr
Place... 7
CONFIDENTIAL
weary WHT,
IDENTITY CERTIFICATE
(ae arvras Pettitte 4 a feet wee eecrefta Bt
(Certificate to be signed by any one of the following):-
(1) efter ore ero area ob errant ata
Gazetted Officers of the Central or State Government;
(2) Sa Patent dea were eee sre TG FAUT WMH ees, Tet mee sterar Gers ATTA / seer are wR
Member of Parliament or State Legislative Assembly belonging to the Constituency where the candidate or his
parents/guardian are residents of;
(3) a Rétora ae / sifted
Sub-Divisional Magistrate/Oficer;
(4) Tenover siren area /m eredtarare oh fs ARREARS aera a weber A ay ag we
Tehsiidars or Nalb/Deputy Tehsildars authorised to exercise magisterial powers;
(8) Se Ara ore eae Tiere / ieee aT Reha /teanee, Tel Y small A ifs Ree Teor a el;
Principal/Headmaster of the recognized School/College/institution where the candidate studied last;
e
(8) Gs Rome aed;
Block Development Orticors;
(7) Sie ae,
Post Master;
(8) area Frere,
Panchayat Inspector,
senfe frar are & fe, Ah / ata / ape, wag A “g
Ree ar Ree FE oa ME A OTT & ate AY fears she Orrranel B sigue gas ere Fey ay aA
Certified that have known ShrilShrimati/Kumati...... ssistsne Sonidaughtor of
Shri. years ......months and that to the best of my knowledge and beliot
the particulars furnished by
‘FETA Signatur
ear ert eee
Designation or Status...
wa
Address. (2)
Prataer rene a7 aT,
vam otk oT
Name, designation and address of
appointing authority
ve, ford fay oaitzay 3 arr
WR fear feat on vert
Post for which the candidate is
being considered
8
CONFIDENTIAL
after’ grr aRT ory
TO BE FILLED BY THE OFFICER
aeitere eres da Pafeea Ber,
‘we FTE
Director Gen Armed Forces Medical Services
Ministry of Defence.
Yo Refbeer are # sreroret War wher WET aA ty
‘fear far on xe 21
Being Considered for grant of
Short Service Commission in the
Army Medical Corps, CONFIDENTIAL
referer
PRIORITY.
KOLKATA-2018 —
tare
_DUPLICATE/SSC ?
en sarera
tea vere & a, rene
MINISTRY OF DEFENCE STOR wT eT
OFFICE OF THE DGAFMS aiet Reve
ASfix signed passport
s retard or size copy of recent
ATTESTATION FORM Py
FOR DETAILED VERIFICATION photograph
WARNING
1
eeu wrt A rere yee Sar era freA oA cearere yee By fora Freda ehh othe opel at, ean gore
3 fay saa wT TET |
The furnishing of false information or suppression of any factual information in the Attestation Form would be a
disqualification and is likely to render the candidate unfit for employment under the Government,
af, ge ord a at ote ge wet @ wear ares Aer gre & VM gee, ara &, aor suet & a gare ater
ears waa oa Petter dar Feary a sire oe won a RY ged meter oe tor war &, GT A
rar 1
If detained, convicted, debarred, etc. subsequent to the completion and submission of this form, the details should
be communicated immediately in the Directorate General Armed Forces Medical Sorvices or authority to whom
the attestation form has been Sent earlier, as the case may be, faling which it wil be deemed to be a suppression
of factual information
ay Pooh mater A Gar thet aE ver aa eR] eal wel A ar YA A mee area Pe cea
‘arrer®) (Gar) w fourar var &, we tare are we A) ATA |
ifthe fact that false information has been furnished or that 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 fo
be terminated
wa /Surname aa /Name
eT (ae oer A) oe aie, af aE
Name in ful (in capital letters) with alases it any
Gar a som fet go ote tat or oe
gra wet art a)
(Please indicate if you have added or dropped at
Any stage any part of your name or surname)
afer gr wen (eat mm, ara qe from seeraT FT
sem, S4/ ste /te, she eras afte fq ats)
Present address in full (i.e. Village, Thana_and
District or House Number, Lane/Street/Road, Town
and PIN Code)
Be ar wa, ea ty ee TT
vem Sa ae/as oe ere, far FEAT aT
am, fa ahs)
Home address in full (e. Vilage, Thana and District
or House Number, Lane/Streel/Road and Town,
name of the District Headquarters, PIN Code)
CONFIDENTIAL Sent wate Pere
2
CONFIDENTIAL
7 sro afte) &_ vet amt ed cia are A ew ae a em a a aftr era fey Poe fem 8)
facet aac Be A, oe eth wert or ther Peer omy Ue eel A 21 ae aH arg ye AS Gea Cw eG afte eB fa
‘rere rar ey
Particulars of places (with periods of residences) where you have resided for more than one year at a time during
the preceding five years. In case of stay abroad particulars of all places where the candidate has resided for
more than one year after attaining the age of 21, should be given
Ran a aT apr ow Gale, am, aT
oe fir Serna Wem,
Ba /sle /te se era, A ate)
Tod waa ¥ eaig ay wr]
2 fre Heo TH
Name “of the District
a bisa Residential address in full (Le. Village, | Headquarter of the place
Fon, ne ‘Thana and District or House Number, | mentioned in the preceding
Lane/Street/Road and Town, name of the | column
District Headquarters, PIN Code)
5.) sare a ater
(a) Details of family:- a
Bae CR | aaa wie wT | aT wR wT eT
wer frye @ | wat ee x @ | Pemanont
eee | oer er | gat yea | ah ite sa 2) | home adcress
am ste seatt | SET ST | sty arafera ar | Present postal
wie Relation | 4; ) ‘eat Bre) petten
lame Nationality | Place ot | oottpaton (i | (dead give
ypinh a ‘employed give | last address)
aralor by Gesigraion &
official address
i wr z 3 4 5 6 7
aT A
wor, af
wig et)
Father Name
in full aliases,
if any e
a
| Mother
|
wen aA oa
Witey
Husband
— 3
CONFIDENTIAL
ae i)
Boner)
ey
Sister(s)
(8) 5 9a (GA) ote /orer A (GA) wh ATT A oe GH Ate aes ae eb / Pram ar eee
(b) Information to be furnished with regards to son(s) and/or daughter(s) in case they are studying/ living in foreign
ccountry:-
a wre Gl cae [Qe wey ow ea | fod sian T aay
Name a / saa Place of birth Br aT ret reer | re Sar fare fare
afar grt) aR x8 2/ Frame ae | 8 reer / Pa oe
Nationality (by 38 Country in we)
birth and/or by which studyingfiving | Date from which
domicile with full address | studying/lving the
country mentioned
aos ae. = in previous column
7 2 3 4 5
6 “
Nationality,
7) or fa
(a) Date of Birth.
(@) xian ong
(0) Present age.
@) Mgaer/dorst wae aeRese Tor} wa Ty
(c) Age at Matriculation/Secondary School Certificate Exam.
8 @) a ae, fre ok eT
(2) Place of birth, District and State,
(@) ren otk wou or are fred arg @
(b) District and State to which you belong,
(9) ya fore, afte aor ar am fore one for ae oe A waft &
(©) District and State to which your father originally belongs.
9. srfReligion. 4
CONFIDENTIAL
40, Retr set aed vert a wel wy weft ge. 15 aE aH ong G FaE she wife A wa Aer areata or atk Bi
Educational qualifications showing places of education, with years in School and Colleges since 15” year of age.
Wad ae ae ON i at a
Name of School/College with full
| address
Date of entry
Ree Vora a fae [ara ag oti
Date of leaving —_| Examination passed
sweat (oot ft) FAR
11.) ar ane are sie ror ara ier Pre actarenn) ar ont vara aah Pro ay fa ware
roa an fire ten some, urge opt a He Y wy & sera aft Pagiar we we 8? aie tere ot
ve aor Fryar (ore) at gt ar AE |
(2) Are you holding or have any time held an appointment under the Central or State Government or a Semi-
Government or Quasi-Govemment body, or an autonomous body or a public undertaking, private firm or
institution? If so, give full particulars with dates of employment up-to-date,
wae Paved ean Ste aR Bahar Reaiaer ST ITA Re ar Gita) oA
om, am and nature of employment address of employer | '@4ving previous service
i z 3 4 5
(6) If the previous employment
was under the Govt. of india/a
State Govt/ autonomous body
University/Local body. if you
hhad lett service on giving a
‘month’s notice, under rule 5 of
the Central Civil Services
(Temporary Service) ule,
4965. or any similar
corresponding rules, where
any disciplinary proceeding
framed against you, or had you
been called up to explain your
conduct in any matter at the
time you gave notice of
termination of services, or at a
subsequent date," before
service, actualy terminated? 5
CONFIDENTIAL
(a).
) FeTiP Fy? T/T oT mM oT / TET
3) Have you ever been arrested? «Yes/No (b)- Have youeverbeen Yes/No
prosecuted?
aay anvet aot aoa farm ra? a /aB | (e) RATT AN aToS E/E
) Have you ever been keptuunder Yes/No erat farar ar? YesiNio
detention? (@) Have you ever been
bound down?
are eg aes ae I/F MUR fae aE T/T
aos cera Yann © Ry fee rey @ fee YesNo
(©) Have you ever been fined by a eretan war 8?
Cour of Law? (9) Have you ever been
convicted by a Court of
Caw for any offence?
(©) ea saat feet ote ae Mor /ae (@) TM sTvay Tee gw Gar A/a
ray evar Roa) fealdatera ay Yes/No svt 3 Swe GT YesNo
fort ara aT / sat feat
Rt snyay Pera veen/arr A Sar
fa) ara? rai/orara ere
(9) Have you ever been debarred a
from any examination or (6) Have you ever been
rusticaled by any University or debartedidigqualfied by
{any olher educational any Public Service
authoriiyfinsttution? Commission rom
ring at
examinaton/selection?
@) wa IEP OM wr ae S778) HOLE rer HL at /at
© Sine. oney Ree Gre YesiNo ae wea aT Fee Yes/No
arate A ag arg coat 8? fart feeatarea/
()Ieany case pending against you rr eet Ae a
in Gour of Law at the timo sarge / | ert
fling up this ‘Attestation Form’? 3 tg re area 2?
(J) Isany case pending
agalnet you in any
iiversity or any other
Educational
Authoriyiinsttution at
the time of fing up this
‘Attestation Forth”
2) ae cpa state WET Aa
Rag scone a Seo
ze HT ag er
are / Pregl / soa /
7 a) OS
sear rarer /
SHE oa are
ae a
vain 21
F the answer to any of the
above mentioned question is
Yee’, give full particular of the
caselarresvdetentio ——fine/
‘conviction
sentence/punishment ete.
and/or the nature of the case
pending in the
‘ourvUniversity/ Educational
Authority etc. at the time of
filing up this ‘Form’ 6
CONFIDENTIAL
NOTE (1) gaa ga wits ont @ it we A ag tare ah aN we
Please also see the ‘WARNING’ at the top of this Attestation Form.
(2) wate wet ar gene oe ‘et eer Sef A a et, a wreae Rar TE
‘Specific answer to each of the question should be given by striking out
"Yes' or ‘No’ as the case may be.
13. ooh WR, (ed) 9 88 Oren mite Fawr et
were 8 te anfeerat } ary any Git onaey array
Name of two responsible persons of your locality (1)
‘or two references to whom you are known
(2)
4 wenfiry aon & fer a mg gutter AR Reare aa & argue we stk yet 81 ge eh aM oat
Boe aE eae Chet ae eT aden
' ceriy that the foregoing information is correct and complete to the best of my knowledge and belief. | am not
aware of any circumstances which might impair my fitness for employment under Government.
spadt & rT
Signature of candidate.
Date. 7
CONFIDENTIAL
agar Ware
IDENTITY CERTIFICATE
(ae sarees Profafter #8 fee ea & weft a) —
(Certificate to be signed by any one of the following):
(1) Beha sera aor eae F eroraPre arranet,
Gazetted Otticers of the Central or State Government;
Cage Pes a ee were aa Toe ar eT ee sre ret oe A/a Fe
‘Member of Parliament or State Legislative Assembly belonging to the Constituency where the candidate or his
parents/guardian are residents of;
3) wa fedora wfc /sftrert,
‘Sub-Divisional Magistrate/Officer,
(4) aeeterer sear ara /oe cederere GY A APSHA Roe after wh water A aA Bey afta ey;
Tehsildars or Nalb/Deputy Tehsildars authorised to exercise magisterial powers;
(6) Se reer are eae / aia / aeons ar Riches /terrece, ret B onal 3 sir fer meer
Principal/Headmaster of the recognized School/College/Institution where the candidate studied last;
©) Ss Rare aftart,
Block Development Officers;
@) Uke are
Post Master;
(8) area fata,
Panchayat Inspector;
safe fot er 8 A AZ APH/ ET Se aaa :
i ‘faut me & arial Cake AN faeara ae Grane & Segue GS are Re ay aA
i
Certified that ' have known ‘Shri/Shrimati/Kumari.. es Son/daughter of
Shii.. for the last ......years ......months and ‘hat to the best of my knowledge and belief
the part ined by bimiher are correct.
WET Signature,
years seat eH
Designation or Status.
we
Address.
fare Date...
IM Place. 8
CONFIDENTIAL
softer’ erat Her oTTy
TO BE FILLED BY THE OFFICER
(1) Preteen sree or as, wattage aeer Or PeAT aa,
ome st wat er Fara
Name, designation and address of |_ Director Gen Armed Forces Medical Services
appointing authority Ministry of Defence.
(2) ve fern} faq oxtcae } ar Ba Referer aie A severe Gar wert ger we oq
vg ture frat at eer & fear fra on ver 21
Post for which the candidate is Being Considered for grant of
being considered Short Service Commission in the
Amy Medical Corps. CONFIDENTIAL
rafter
PRIORITY
TRIPLICATE/SSC
Sea a Bra Ga, ore
MINISTRY OF DEFENCE SaRBTR HT eT
OFFICE OF THE DGAFMS tet fvary
ae Affix signed passport
ATTESTATION FORM Se ey ct eet
FOR DETAILED VERIFICATION photograph
dara
WARNING
erie prt # nea quar Gar sera feet A cearere qed ay fora Arar eth oe onal wt, aE MoT
@ fay otha wren ITT)
‘The furnishing of false information or suppression of any factual information in the Attestation Form would be a