ATTESTATION FORM 

WARNING

 

Text Box: Affix  a signed Passport size (5cms X 7 cms approximately) copy of recent photograph here without defacing the identity

 

 

 

 

 

                                           1.   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.

 

2.   If detained, arrested, prosecuted, bound down,

      fined, convicted, debarred, acquitted, etc.,

      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 early, failing

      which it will be deemed to be a suppression of

      factual information.

 

3.   If the fact that false information has been

      furnished or there has been suppression of any

      factual information in the attestation form comes

      to notice at a time during the service of a

      person, his/her services would be liable to be

      terminated.

 

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1.         Name in full (IN BLOCK         

            CAPITALS) with alias, if any.

            (Please indicate if you have

            added or dropped in any

            stage any part of your name

            or surname)

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2.         Present address in full

            (i.e. Village / Thana /

            District or House No./

            Lane / Street / Road / Town

            and name of District Hqrs.)

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3.         (a) Home address in full

            (i.e. Village / Thana /

            District or House No./

            Lane / Street / Road / Town

            and name of District Hqrs.)

 

            (b) If originally a resident of

            Pakistan, the address in

            that country and the date

            of migration to Indian Union

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4.         Particulars of places (with period of residence) where you have resided for more than one year at a time during the preceeding 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.

 

Sl. No.

From

To

Residential address in full (i.e. Village / Thana / District or Door No. / Lane / Street / Road and Town)

Name of the Hqrs. of the places mentioned in the preceeding column

 

 

 

 

 

 

 

 

 

Members of family

Name

(with alias, if any)

Nationality

Place of Birth

Occupation (if employed, giving designation and Office address

Present postal address and permanent Home address

 

1

2

3

4

5

Father

 

 

 

 

 

 

 

Mother

 

 

 

 

 

 

 

Wife / Husband

 

 

 

 

 

 

 

Brother (s)

 

 

 

 

 

 

 

 

Sister (s)

 

 

 

 

 

 

 

 

 

  

5.         Information to be furnished with regard to son(s) and daughter(s) in case they are studying / living in a foreign country. 

Name

Nationality (By birth or Domicile)

Place of birth

Country in which studying/living with full address

Date from which studying in the country mentioned in previous column

 

 

 

 

 

 

 

 

 

6.         Nationality (by birth or Domicile)                     :

 

7.         (a) Date of birth                                               :

 

            (b) Present age                                               :

 

            (c) Age at Matriculation                                   :

  

8.         (a) Place of Birth/District & State in                  :

                  which situated 

            (b) District & State to which you                       :

                  presently belong 

            (c) District & State to which your                       :

                  father originally belonged 

 

9.         (a) Your religion                                               :

 

            (b) Are you a member of                                    :           SC / ST / OBC

                  (strike out whichever not applicable)

           

            (c) Name of the Caste                                       :

 

            (d) Category of candidature                                :           PH / EX-SM / Dependents of 

                  (strike out whichever not applicable)                    EX-SM  killed in action

  

10.       Educational qualification showing places of education with years in School(s)

            and Colleges(s) since 15th year of age. 

 

Name of  School/ College with full address

Date of entrance

Date of leaving

Examination(s) passed

 

 

 

 

 

  

11.       (a)        Are you holding or have any time held an appointment under the Central or  State Government or a Semi-Government or a Quasi-Government body or an Autonomous body or a public undertaking or a private firm or institution.  If, so, give full particulars with dates of employment, up-to-  date. 

 

period

Designations, Emoluments and nature of employment

Full name and address of the employer

Reasons for leaving previous service

From

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

            (b)        If the previous employment was under the Government of India / a State

                        Government / an Undertaking owned by or controlled by the Government

                        of India or a State Government / an autonomous body / University / local

                        body. 

                        (state whether you had left service on giving a month’s notice under Rule 5

                        of Central Civil Services (Temporary Service ) Rules, 1965, or any similar

                        corresponding rules where any disciplinary proceedings framed against    

                        you, or had you been called upon to explain you conduct in any matter at

                        the time you have been served with notice of termination of service, or at a                                    subsequent date, before your services were actually terminated).

 

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

 

            (b)        Have you ever been prosecuted?                   :           Yes / No

 

            (c)        Have you ever been kept under                      :           Yes / No         

                        detention?

 

            (d)        Have you ever been bound down?                 :           Yes / No

 

            (e)        Have you ever been fined by a Court              :           Yes / No

                        of Law?

 

            (f)         Have you ever been convicted by a                :           Yes / No

                        Court of Law for any offence?

 

            (g)        Have you ever been debarred from any         :           Yes / No

                        examination or restricted by any

                        University or any other educational

                        Authority / Institution?

 

            (h)        Have you ever been debarred /                       :           Yes / No

                        disqualified by any Public Service

                        Commission/Staff Selection Commission

                        for any of its examinations / selections?       

 

            (i)         Is any case pending against you in any          :           Yes / No                     

                        University or any other Educational

                        Authority / Institution at the time of

                        filling up this Attestation Form?

 

            (j)         Is any case pending against you in                 :           Yes / No

                        any Court of law at the time of filling

                        up this Attestation Form?

 

            (k)        Whether discharged/expelled/                        :           Yes / No         

                        withdrawn from any training institution                      

                        under the Govt. or otherwise?

 

                        If the answer to any of the above mentioned questions is “Yes”, give full particulars of the case Viz. arrest/detention/fine/conviction/sentence/punishment, etc., and the nature of the case pending in the Court/University/Educational authority, etc. at the time of filling up of this form. 

NOTE             :           (i)         Please also see the ‘WARNING’ at the top of this 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 addresses of two responsible persons of your locality or two references

            to whom you are known. 

 

(1)

 

 

 

(2) 

 

 

                        I CERTIFY THAT THE FOREGOING INFORMATION IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.  I AM NOT AWARE OF ANY CIRCUMSTANCES WHICH MIGHT IMPAIR MY FITNESS FOR EMPLOYMENT UNDER THE GOVERNMENT OF INDIA.

 

 

Date    :

 

Place   :                                                                       Signature of the candidate