Verification Roll
Recent
Passport
Size
PhotograPh
[Link] in pull (ln block capitals) with
aliases, if any. (Please indicate if you
have added or droPPed, at anY stage,
any part of Your name or surname)'
The name of the Post and service
Present address in full (i.e. village, or
house number, lane/street and road,
Police Station and district, Prn!eqe
[a) Home address in full (i.e. village, or
house number, lane/street and road,
Police Station and district, PIN, Contact
Number)
(b) If originally a resident of Pakistan,
Bangladesh, NePal or any other
country, the address in that dominion
of misration to Indian Union.
5. Particulars of Places where You have resided for more than one year during the
preceding five years
Residentiat address in full (i.e. village or house
number,lane/street and road, Police Station and
6. [a) Father's name in full with aliases, if ...[a)
any
tb) Present Postal address fif dead, give ...tb)
the last address)
(c) Permanent home address ...(c)
td) Profession ...td)
(e) If in service, give designation and ...(e)
official address
[Continued to next Page]
2-
7. (i) NationalitY of---
(a) Father ...(a)
tb) Mother ...(b)
(c) Husband ...(c)
td) Wife ...(d)
B. ta) Exact date of birth [To be supported ...(a)
bYBirth Registration
Certificate/Admit Card of West
Bengal Board of SecondarY
Education/anY other recognized
Boardl
(b) Present age ...tb)
(c) Age of Matriculation/School Final ...(c)
g. ta) Place of birth, Police Station, district ...(a)
and State in which is situated
(b) District and State to which You ...(b)
belong
10. [a) State Your religion ...(a)
Are you member of scheduled caste/ ...tb)
tb)
Scheduled tribe/ OBC. Answer "Yes"
or "No" and if the answer is "Yes"
state the name thereof. [CoPY of
certificate to be attached]
11. Education qualifications showing place of education with year in school
colleges:
Name of school/colleges with full Date of Examination
address with Police Station, Pin Date of Entry: leaving: passed:
Code, District & State:
[Continued to page-3]
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12. If you have at any time been employed give details
Designation of the Full address of the office, firm or
Post institution and reasons for leaving
held or descriPtion of previous service
work
13. Have you ever been convicted by a Court
ofany offence or charge-sheeted by the
police in connection with any criminal
proceeding? If so, the full particular of the
case should be given.
L4. Name of wvo responsible persons of your
locality or tvvo referees to whom you are (1)
known
(2)
I certify that the foregoing information is correct and complete to the best of my
knowledge
might impair my fairness for
and belief. I am nol u*"r" of my circumstances, which
information will
employment under the Government. I understand that submission of false
make me ineligible for employment.
(signature of the candidate)
Place
(Certificate to be signed by a gazetted officer)
Certified that I have known Shri/Shrimati.........
Son/daughter of Shri.......... for the 1ast""""""""' years
months and that to the best of my knowledge and belief the particulars furnished
by him/her are correct.
Place Signature.
Date Designation status and address
Signature and designation of the Issuing Offlrcer and
the name of the office with full address and date.
