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.