ANNEXURE -I

ATTESTATION FORM

“WARNING: The Furnishing of false information or suppression of

any factual information in the Attestation Form would
be disqualification, and is likely to render the
candidate unfit for employment under the
Government.

Affix signed passport size (5 cm. X 7 cm. 2. If detained, arrested, prosecuted,

Approx) copy of recent photograph where bound down, fined, convinced,
asked for. 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 service
would be liable to be terminated.”
_____________________________________________________________________________________
1. Name in full (in block capitals) with SURNAME NAME
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 No.
Lane/Street/Road and Town.
____________________________________________________________________________________
3. (a) Home Address in full (i.e Village,
Thana, and District or House No.
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.

_________________________________________________________________________
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 Name of the District
full (i.e. Village, Thana Headquarters of the place
and Distt. or house No. mentioned in the preceding
Lane/Street/Road and column)
Town).
________________________________________________________________________________
5. Name Nationality Place Occupation Present Permanent
(by birth & or of birth (if employed Postal address Home
by domicile) give designation (if dead give Address
& official last address)
address)
________________________________________________________________________________
(i) Father
(name in full
aliases, if)
any
(ii) Mother
(iii) Wife/Husband
(iv) Brother(s)
(v) Sister(s)
________________________________________________________________________________
5. (a) Information to be furnished with regard to sons(s) and/or daughter(s) in case they are studying /living
in a foreign country:
________________________________________________________________________________
Name Nationality (by Place of Country in which Date from which
birth and/or by birth studying/living studying/living in the domicile)
with full Address. 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 and (a)
State in which situated
(b) District and State to which you belong. (b)
(c) District and State to which your father (c)
originally belong.
_________________________________________________________________________________
9. (a) Yours 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 years of age.
__________________________________________________________________________________
Name of School/College Date of entering Date of leaving
Examination passed
with full address
__________________________________________________________________________________

___________________________________________________________________________________
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 Full name Reasons for
From To and nature of employment and address leaving previous
of employer service.
___________________________________________________________________________________

____________________________________________________________________________________
11. (B) If the previous employment was under the Government of India, a State Government/
an Undertaking owned of controlled by the Government of India of a State Government/ an
Autonomous Body/University/ Local Body.
____________________________________________________________________________________
If you had left service on giving a month’s notice under the rules 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. (1) (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 application form? Yes/No
(j) Is any case pending against you 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
12. If the answer to any of the above mention 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. Name 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 _______________________________
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IDENTITY CERTIFICATE
(Certificate to be signed by anyone 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 Tehsildar authorised 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-Master;
(viii) Panchayat Inspectors.

Certified that I have known Shri/Smt./Kumar________________________________son/ daughter of

Sh. ___________________________ 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 BY THE OFFICE

(i) Name, designation and full address of the appointing authority.

(ii) Post for which the candidate is being considered.

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