P a g e 1 | 8 ATTESTATION FORM Name of the post: ‘WARNING: 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 Affix signed passport size (5 cm. x 7 cm. approx.) copy of recent photograph – where asked for 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 earlier, 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 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 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 Number, Lane/Street/Road and Town). 3. (a) Home Address in full (i.e Village, Thana, and District, or House Number, Lane/Street/Road and Town and name of District Headquarters. (b) If originally a resident of Pakistan/Bangladesh (erstwhile East Pakistan the address in that country and the date of migration to Indian Union.
P a g e 2 | 8 4. 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 (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, Thana and Distt. Or house No./Lane/Street/Road and Town) Name of the District Headquarters of the place mentioned in the preceding column 5. Name Nationalit y (by birth and/or by domicile Place of birth Occupation (if employed give designation & official address Present Postal address (if dead give last address Permanent Home address (i) Father (Name in full aliases, if any) (ii) Mother (iii) Wife/ Husband (iv) Brother(s) Brother(s) (v) Sister(s) Sister(s)
P a g e 3 | 8 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 Name Nationality (by birth and/or by domicile Place of birth Country in which studying/living with full address Date from which studying living in the country mentioned in previous column 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 Caste/Scheduled Tribe? Answer ‘Yes’ or No. 10. Educational Qualification showing places of education with years in Schools and Colleges since 15th Year of age Name of School/College with full address Date of entering Date of leaving Examination passed
P a g e 4 | 8 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 Designation, emoluments and nature of employment Full name and address of employer Reasons for leaving previous service From To 11. (B) If the previous employment was under the Govt. of India, a State Govt./an Undertaking owned or controlled by the Government of India or a State Government/an Autonomous Body/University/Local Body. If you had left service on giving a month’s notice under rule 5 of the Central Civil Services (Temporary Service) Rules, 1965 or any similar corresponding rules were any disciplinary proceedings framed against you, or had you been called upon to explain your conduct in any matter at the time you gave notice of termination of service, or at a subsequent date, before your services actually terminated? 12. (i) (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 (g) Have you ever been debarred from any examination or rusticated by any University or any other educational authority/institution ? Yes/No (h) Have you ever been debarred/disqualified by any Public Service commission/Staff Selection Commission for any of its examination/selection ? Yes/No (i) Is any case pending against you in any Court of Law at the time of filling up this Attestation Form ? Yes/No (j) Is any case pending against you in any University or any other educational authority/institution at the time of filling up this Attestation Form ? Yes/No (k) Whether discharged/expelled/withdrawn from any training institution under the Government or otherwise Yes/No
P a g e 5 | 8 (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 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. Names of two responsible persons of your locality or two references to whom you are known 1. Phone No. Address: 2. Phone No. Address: 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 Government. Signature of Candidate___________________________ Date:_________________________________________ Place_________________________________________
P a g e 6 | 8 IDENTITY CERTIFICATE (Certificate to be signed by any one of the following): (i) Gazetted Officers of Central or State Government; (ii) Member of Parliament or State Legislature belonging to the constituency where the candidate or his parent/guardian is ordinary resident; (iii) Sub-Divisional Magistrates/Officers; (iv) Tehsildars or Naib/Deputy Tehsildars authorized to exercise magisterial powers; (v) Principal/Head-Master of the recognized School/College/Institution where the candidate studied last; (vi) Block Development Officer; (vii) Post Masters; (viii) Panchayat Inspectors. Certified that I have known Shri/Ms.……………...……..………………son/daughter of Shri…………………………………..for the last……….years……...months and that to the best of my knowledge and belief the particulars furnished by him/her are correct. Date………….. Signature………………………………… Place………………… Designation or status and address: TO BE FILED BY THE OFFICE (i) Name, designation and full address of the appointing authority (ii) Post for which the candidate is being considered
P a g e 7 | 8 ANNEXURE ‘A’ To, _______________________________ _______________________________ _______________________________ _______________________________ Subject: Acceptance of the offer of appointment for the post of Auditor- regarding. Sir / Madam, I do hereby accept the offer of appointment to the post of on probation on the terms and conditions mentioned in your letter No. ___________________________________ dated __________. I request you to kindly arrange for my medical examination at the earliest / I am already serving in the Deptt. __________________ (Name of the Department) as _____________ (Name of the post) under Central / State Govt. I was medically examined and found fit at the time of joining the said post. A certificate to this effect from my existing employer is enclosed. My particulars are given as under: Name ________________________________________________________________ Father’s Name _________________________________________________________ Complete Address (Clearly indicate the name of the District and PIN Code). Date of birth by Christian era _____________________________________________ Exact height (by measurement) in Centimeters _______________________________ Personal marks for identification __________________________________________ Yours faithfully, Signature of the candidate Date:_______________ Phone no._________________
P a g e 8 | 8 ANNEXURE “B’ 1. I, Shri /Smt./Kum ____________________________________hereby declare as under:- (i) That I am unmarried /a widower / a widow. (ii) That I am married and have only one wife living. (iii) That I am married and have more than one wife living. (iv) That I am married and during the life time of my spouse I have contracted another marriage. (v) That I am married and my husband has not other living wife, to the best of my knowledge. (vi) That I have contracted a marriage with a person who has already one wife or more living. 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 application, I shall be liable to be dismissed from service. Dated:________________ Signature :________ __________ Note: * Please delete the clauses not applicable.