Attestation Form

OFCH.,.. 467
ATTEST ATION
,
FORM
'
yvARNING:- Thefurniahing of false information or suppression
of ahY ,factuat inforrrfation in the Attestation'Form would 1:>ea
.disquaHfic~tion,andis lil<.elYto render, 'the candidate unfit for
employment under the Government.
'
J
2. If detained convicted, debarredetc, subsequent'to the com',.
',', ' ,
pletion and subm;ssio.nof this form, the details should be commu/ Affix sigf'l8d~8$sportsize nicated immediately tothe Union Public Service CommiSSionOf,
(501ns. x ;.cms.approx.)
, copy of rec~ntphotograp the authority tovyhom the Attestation Form has been sent'earlier'
WA,re asked for,
as the case maybe failing which it will be deemed ~ be
"
suppressionoffactuel information.
.
"
a
3 If the fact thatfalse inforrpation has been furnished or that
.there. h~sbeen suppression of any factualfnformation.in
the
Attestation Form comes to notice at anytime during the $ervice
ofa·person. hi~ services would be terminated.
)
1.
2.
Namei~ Full'
,
" (13IQck'iq~pt~~l.With aliases, if any.
(PJ'.lnDi~ate if you have,added
or d.ropped in any stage any part of
your Name or Surname)
Pt..,ntAddressinfuU'
{f.iJ;'VitfagEti Tflan~ and District or
House No.7Cine/St'reet IRoad and Town).
3.
(a) Home Add;essin~uU, .
( i. e. Village, Thana and District
or House No,/LanejStreetjRoad
TOWrlandName of District Hqs).
(tJ) f1'''irginaUy a resident of Pakistan
th, Address in that Country
and the o ate of Migration
to Iridian Union.,
4.
Particulars'of Places ( with periods of residences) where you hava rasided for mora than
one year ata time during~he precepd,:ngfive years. Incase of stay aproad ( including
Pakistan) particulars of all places where you have resided'for more thGlnone year after
attainitlg the age of 21 years should be given.
'
From
To
Residential Address i~ FUI; ',1 Name of the listt Headquarters
(i e. Village, Th'ina and
of the. place mHntioned in the
District'or House No./Lanej
preceedirg column.
Street/Read and,Town)
a) Information to be furnished with regard to son(s) and
. are studyingfPving in fo~eign· countr\{,:
Nationality: I
(by Birth and/'. Place of,
-Birth
or by Domicile
r
I
I
I
-_ __._-~_".~
.•.•
~"..,...,..,.
'.
6.
:'
Nationaljty
__
..
i,
daughtEr
' Date from which
'Icoun.t~y ~nv~h:ich s~udying fliving
study;ng / llv:ng
In the} country
with Full Address
mentioned in
i
.'
pr~vious column
I
l
",,..._ .•.,,_ •..•__•._"C"l"''''' ..r~~,,,,_,,,:,,,,,,,.-:,,,"_·~.,,",,"-..._lri"_.a.·.~=.
.•..•..
_,.~_'7::~.~~
__
.
....,.---.
7.
.~""-",~_~.~:
lor
a) Date af Birth
b) Present Age
c) Age of Matriculation
a) Pla~e' of Birth
(District and State in which situated).
b) District and State to which you belongs.
c) District and State to whichyour father
- originally belongs.
b)'
c) _
a} Your Religion
b) Are YOU a member of a Sch'eduled Castel
Scheduled Tribe? Answer 'Yes' or 'No' and
if the answer is 'Yes' state the name-thereof.
10. Educa"tional Ol,lalification showing places ofedu~~ti;;,-;it'hy~~r;;;S-ch~dC~lIeges
si'nce 15 th years of age.
'
....--,
••.••.••
__ ._\
•••.••..
_.
, ••••••..~,
•••••••••••
:~
••••• ~
.• __
••_._-,
••. ~.~----
__~-
j
Name of School/College
with Full Address
Date of
.' Entering
I
.~,_".==JC_
.
..
.
..::-. __ ,_,
'I
I
.
•.
.
..- __
.__
" __
Date of - \.
Leaving.
OlIK.,_.
_'.........--
•••• "",~ .•..••••••_.
_
Examination Passed
I
j
II
~~~._,."=.~~f~...~.
.'
.•• ,~-,
J
I
j
.,-------
11. a) Are you ho!c! ng or have any time held an appointment under the Central GqVt. or
State6ovt. or 8 S~mi Govt. body or Quasi-Govt. body or, an Alltonomous
body or
a Public Undertaking or a Private -Firm or institl:ttion?
If so, give full pa,tic;;ulars
with dates of employment up-to-date.
.
--peri6d~-~'-1
DeSign~~oErmol_
~
.. /
From-.
¥
To
.
J
j
I
I
1.-
I
I .
~-~:~·~'y:~~~~:;"-'~-
~~~~_··_"*-~U-I-I~
~;~
a
Nature of Employment
-
-
of Em,ployer
Leaving
previous service
11. II)
lfthe previous. employmeo~ Waf -'·'~~·(i()Vt.of,ndi~:()t'~:~~t~"G(jyt.1an\lildJL. '{Being owned or contfoll~d by't1'le '/t)1Jndiao(a
~tate'Govt.la.J1. AutOJl()fl1QU$
. bOdy'l Univ8f-$ity Il.oeat;body~
, .~::- ".
Ify~U ha~,~~~::'>{'
"'tiAAlAndQrRUle
.....:s.,vic__.,(.ttrnPQr-ants~.lRJaI$$f.
.any discipHnary-proeeediftt}$;f•• _
in any
,explain y~ur.conduct
. JCtwaltytli'rminated ? .
matter
...
'.'
5
rules where'
. '~er;had you been called up()tl~{o
'Mou.cgavenotlceof
termination
at
Yesj No
Y8$~NO
.; ~.:
Yes/No,
.
a Court of .Law?
. .. ¥~:~rt.of.~awfor
)f(~' .,.
. '.
·.•·•.··an'fU~~':om~~.<'
.'
YiJs1No
' "y .. ', ·.·Y~J,NN' 00.
.' .
anyo.ffence'r
.orrtjstrcsted by
...
~~.
tioht
v
_
Xes./No.
i •.
.' .'.. ..'
. Co-rnmiSsionfromappearing'iafi.
..
.
.'.
.
Yes/No·
i) ~Isany case pending against you in any Coun'of law at-th~tlmeof
.' fitHng-upthis Attestation Form? .
..'~
!
j) ..Is~ny~.~Ptndjng::againstVo~jil;8llY LJniveJ'Si.lyOf·~.ny,~r
~
Ed~AuthOrityllnstituttPn
at ,tb&~timeoffin: I1g.•.•up this
.'j
AttestatiOnhrtn1.
,'
'.
-
--
:,
~ ~ - . '- '.:,' -.",i'!
. . ,~~
.
.
Civil
.
dlH~,;~.oe\ieIL~eeril>gurni(down?
1.l)""a\,le;YOuEJ.\,lerb~'
th: Cel1t~
cf
.·.Y~s'imil~corresponding
. 12. (I) a) Have:y()t.r',v~·Q~e,narres.ted?~··,
. b) HaveVoo·~VJ{~;Pfq~.Cut~7
e)Havey()u;:e~/be~n'.k:~ptil}l(ie-rdetention 1
.~·H~~;~.,
. '~~9tlJ~PY
:f}::Ha~,¥• .i .":,....
g,)·Hct~~ ..~efbe~p:·
,:
.,
.
.
Yes··,···N··
C)
".
'
Yes/No
""i"
, ats
.C.,iV\d
or
cationsl' Authorrtt~,~~ ..
\ : s'~:::~
'''Itl:-'I) PI~asealso
arettfe'iWarningn~~ttbetoPofthisAttestaionForlll'
~'~'.'
I
." jj)':$p~cifieflnswers to •..eacn.9f~the,question· should be .given~y:-'striking out
v
';'::>:-!'~~:':~(:NQ'
as Jb.,;~,.'_be.'
~". ':'
_,-
--'-'-~",:,~,_:::.),-_.,.~-_,-,':
"
' 13.:N~e:atTwo?'ieSponsible
~or
.
"
1 ..
,..,
...
> .. ,._.,.:.;>'::',:
persons of '
.veNT: k.>cafity .Two· reference~to
you ;a~.:
kno-wn.
. ....
,.~.
i(,
I
,:,.,~-- - ,-
$>~~,',#::;} ,
.'
,
i~eto the b~tOff1lYj
:~~igtlfimpatr
rnVf~
.;
Signature of Candidate'·
.
~"._:-
'
IDENTITY
(Certificate to be'.~ned
i) Gazetted Officers of Central .r
cartlFICATE
W
anyone of the following)
State GovE)mment ; .
.ii) Members of Parliament or State 14leJ~ures.belonging to ttle constituency where the
candidate.r his parent/guardian is ofiirPI,ily ,.ident;
iii) Sub-Divisional Magistrates/Officers;
.iv) Tehsildars or NaibjDeputy
Tehsltdars authorised to exercise magisterial powers;
v) Principal I HeadMaster of the recognised School
candidate studied last;"
1
College
1
Institution
where the
vi) Blotk gevelopmtnt Offi~.;
vii) p.ost Mastef.$;
. .
viii) P'anchayat Inspector•.
C~rtified tDat I have known ShrU Smt. 1 Kumari ... - •... i
SOM
I wife
t
.
.
'.'
, .-" .
/d$QQhterof .Shri
••..••• ' months -Blidthatto
by hini/htr
.
.•.. _..... , . ; •.. . • ..• ..•.•.•.•• .._.....
the~~ltt ef my knowle_,eand
" •• '•••.••••
-
••••.
for the last ..•.•• e.
••
_. _
•.••
'
years
belief the particulars furnished
·are. cQrre9!·
Des1gnationor Status and AddresS.
(i) Name, 06$ignation. B·nd Fun. Ad.d[~ss·of·th&·:IRp'Ointingauthority.