ATTESTATION FORM
Affix signed passport size 5cmx7cm approx copy of recent photograph where asked for |
WARNING: 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 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 your have added or dropped in any stage any part of your name or surname) |
SURNAME |
NAME |
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, the address in that Country and the date of migration to Indian Union. |
|
|
(i) 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 |
Nationality (by birth and/or by domicile) |
Place of birth |
Occupation (if employed give designation and official address) |
Present Postal address (if dead give last address) |
Permanent Home Address. |
(ii) Father (Name in full aliases, if any) (iii) Mother (iii) Wife/Husband (iv) Brother(s) (v) Sister(s) |
|
|
|
|
|
|
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 (a)
(b) Present Age (b)
(c) Age at Matriculation (c)
8. (a) Place of birth, District (a)
and state in which situated
(b) District and State to (b)
which you belong
(c) District and State to
Which your father originally belong (c)
9. (a) Your religion :
(b) Are you a member of a Scheduled Caste/
Scheduled Tribe? Answer ‘Yes or No’
(iv) Educational qualifications 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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
(v) (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 institutions? 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 Government of India, a State Govt./an undertaking owned or controlled by the Govt. of India or a State Govt./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 were actually terminated?
12 (i)
(a) Have you ever been arrested? (b) Have you ever been prosecuted? (c) Have you ever been kept under detention? (d) Have you ever been bound down? (e) Have you ever been fined by a Court of Law ? (f) Have you ever been convicted by a Court of Law for any offence? (g) Have you ever been debarred from any examination Or rusticated by any University or any other Educational authority/institution? (h) Have you ever been debarred/disqualified by any Public Service Commission /Staff Selection Commission for any of its examination/selection? (i) Is any case pending against you in any court of law at the time of filling up this Attestation Form? (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? (k) whether discharged/expelled/withdrawn from any training Institution under the Government or otherwise?
|
Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No
Yes/No
Yes/No
Yes/No
Yes/No |
12 [ii] If the answer to any of the above mentioned questions 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.
(vi) 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 1.
Your locality or two references to whom 2.
You are known.
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;
IDENTITY CERTIFICATE
(Certificate to be signed by any one of the following)
i. Gazetted Officers of Central or State Government;
ii. Members of Parliament or State Legislature belonging to the constituency
where the candidate or his parent/guardian is ordinarily resident;
iii. Sub-divisional Magistrates/Officers,
iv. Tehsildars or Naib/Deputy Tehsildars authorised to exercise magisterial powers,
v. Principal/Head-Masters of the recognised School/College/Institution where the candidate studied last;
vi. Block Development Officer;
vii. Panchayat Inspectors.
Certified that I have known Shri/Smt./Kumari _________________________ _______________son/daughter of Sri _______________ 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 FILLED IN BY THE OFFICE
(i) Name, designation and full address of the appointing authority.
(ii) Post for which the candidate is being considered.
Ref: Railway Board letter No. E(D&A) 82GS4-1 dated 21.4.1983 [1]
Links:
[1] http://indianrailwayemployee.com/content/character-and-antecedents-verification-railway-employees-appointment