Post on 31-Mar-2018
Office of the Chief Commissioner, Central Excise, Jaipur Zone, Jaipur List of candidates called for submission and chekcing of documents
Date 09.05.2016 (Monday) Time : 10 A.M.
1 SHRI SHANKEY CHUGH 19 SHRI PINKAL AGARWAL
Ward No. 20, Vikas Nagar, Sri Vijay
Nagar, Sri Ganga Nagar, Rajasthan -
335704
House No. 139, Krishna Colony, Jeoni Mandi,
Agra, Uttar Pradesh - 282004
2 SHRI PRANAV SHARMA 20 SHRI ANUJ AGGARWAL
128 Mahadev Nagar, Near Akshardham
Mandir , Vaishali Nagar, Jaipur,
Rajasthan- 302021
House No. 34, Sector 7 A Faridabad, Haryana -
121006
3 MS. PRIYA SENGAR 21 SHRI ANANT KUMAR GARG
C 4/1 EXTENSION 4 Kamruddin Nagar,
Nangloi, Delhi - 110041
67/231, Sector-6 , Pratap Nagar, Sanganer,
Jaipur - 302033
4 MS. NIDHI CHAHAR 22 SHRI AWADHESH UPADHYAY
13/123, Char Bagh, Shahganj, Agra,
Uttar Pradesh - 282001
Vill Madhwapur, Post Bargadwa, Basti , Uttar
Pradesh - 272190
5 SHRI AMIT YADAV 23 SHRI DEEPAK
J-6- PHP, Dwarka Sector 16 B Dwarka,
Delhi - 110078
Village Kisoli , Post Kisoli, Bulandshahr, Uttar
Pradesh - 203408
6 SHRI RAHUL CHOUDHARY 24 MS. PUSHPA 4/2631 OTC B-Block, Sajjan Nagar,
Sajjan Garh Main Road, Udaipur,
Rajasthan - 313001
1338 Janta Flats, GTB Enclave Near GTB
Enclave, Delhi - 110093
7 SHRI ANCHAL AGRAWAL 25 SHRI NITESH KUMAR TIWARI
Moh. Kila, Saroj Bhawan, Jalesar(ETAH)
Salesar, Uttar Pradesh - 207302
VPO-ANDHI, Teh-Jamwaramgarh, Jaipur,
Rajasthan - 303001
8 SHRI RAKESH KUMAR SHARMA 26 SHRI AJAY KUMAR 2/141 N.E.B. Housing Board, Near Manju
Hospital, Alwar, Rajasthan - 301001
H.No. 2/543, New Patel Park, Line Par, Near
New Bal Vikas High School, Bahadurgarh,
Haryana - 124507
9 SHRI DHEERENDRA KUMAR
SHARMA
27 SHRI SUMIT BISHNOI
2/28, Kala Kuan, Housing Board Alwar,
Rajasthan - 301001
House No. 3, Sector No. 3 Behind Govt. Hospital
Hanumangarh Town, Rajasthan - 335513 10 SHRI KAPTAN SINGH 28 SHRI PARDEEP KUMAR
Village Taragwan, Post Ghantry, Tehsil
Weir, Bharatpur, Rajasthan - 321409
H.No - 87 Ward No - 3 Sir Chotu Ram Colony,
Uchana, Jind, Haryana - 126115
11 SHRI KRIPA SHANKAR SINGHWAL 29 SHRI NEERAJ BHATT
VPO - Natoj, Via - Kherli, Teh-
Kathumar, Alwar, Rajasthan - 321606
C-2/239, Gali No-06, IIND Pusta, Sonia Vihar,
Delhi - 110094
12 SHRI SAHIL 30 SHRI ABHINAV SHARMA
802 Tilak Nagar, Rohtak , Haryana -
124001
D-737 Type - III Mandir Marg, New Delhi, Delhi
- 110001
13 SHRI AKHIL SHEORAN 31 SHRI RAMIT MEHLA
Quarter No. 57, G Floor, Police Station
Colony, Civil Lines, New Delhi - Delhi -
110054
H.No. 764, Sector 5 U.E. , Kurukshetra,
Haryana - 136118
14 SHRI GAURAV GOYAL 32 SHRI PRINCE KUMAR
40 A Fashion Shoes, Gali No. 2, Adarsh
Basti, Tonk Phatak Jaipur , Rajasthan -
302015
13 398, Gobind Nagar, Street No. 4, Sirsa,
Haryana - 125055
15 SHRI YOGESH SHARMA 33 SHRI AMANDEEP GAUR
H.No. 219, Durga Colony, Ward No. 13,
Hanumangarh Junction, Hanumangarh,
Rajasthan – 335512
House No. 68, Sector 3 Part 2 Huda, Rewari,
Haryana - 123401
16 SHRI KULDEEP SINGH RAJPUROHIT 34 SHRI ASHISH KUMAR SHRIVASTAVA
Rajpurohiton Ka Bass, Indira Colony
Bikaner, Rajasthan - 334001
H.No. 979/31, Phase 1, Street 1 C, Laxman
Vihar, Gurgaon, Haryana - 122001
17 SHRI MANAS UDENIA 35 SHRI MOHAN TIWARI
Markandeshwar Mandir, Near Old Subji
Mandi Palace Road, Kothi, Dholpur,
Rajasthan - 328001
H.No. 204/24, Subhash Nagar, Near C.R.A.
College Sonipat, Haryana - 131001
18 SHRI ANURAG KUMAR TRIVEDI
C/o Binod Kumar Pathak, D-310 Third
Floor , Nawada Housing Complex,
Kakrola Mode New Delhi - Delhi -
110059
Office of the Chief Commissioner, Central Excise, Jaipur Zone, Jaipur List of candidates called for submission and chekcing of documents
Date 10.05.2016 (Tuesday) Time : 10 A.M. Shri / Ms.
36 MOHIT KHURANA
54 ROHITASHWA KUMAR YADAV
H.No. 118, Bhai Parmanand Colony, Near
Mukherji Nagar, Delhi - 110009
Vill - Papra, Post - Kuhara, Teh - Viratnagar,
Jaipur, Rajasthan - 303102
37 NITIN GUPTA 55 PRADEEP BHURIA
A-3/188, Sector - 17, Rohini Delhi - 110089
190 A-1, Sunder Vihar, OPP. Power House,
Kalwar Road, Jhotwara, Jaipur - Rajasthan -
302012
38 MOHIT ARORA
56 ARMAN
B-28, Sunder Appartmens, Plot No. -13,
Sector - 14, Rohini, New Delhi, Delhi -
110085
S/o Abdul Hafiz, Nagar Panchayat-Jhanjharpur,
Ward No. 12, Near Madarsa Chowk, Distt.
Madhubani, Bihar - 847404
39 SWATI SHARMA
57 DEEPAK MAHALA
H.No. 1485/20, Hargobind Nagar, Near
Balaji Mandir, Kurukshetra, Haryana -
136118
VPO-Jankipura VIA-Jajod, Teh - Srimadhopur,
Sikar Rajasthan - 332722
40 NEPAL
58 ARUN SINGH GURJAR
VPO - Sanjarwas, Tehsil Charkhi Dadri,
Dist. Bhiwani, Haryana - 127042
Bard No. - 06, Gurjar Pada, Vill / Post - Rendayal
Gurjar , Teh-Bajeerpur, Sawai Madhopur,
Rajasthan - 322220
41 HIFZAAN KHAN 59 PRADEEP KUMAR
House No. 124,125, Block -E Madipur
Colony, Near Madipur Metro Station, West
Delhi , Delhi - 110063
Siv Colony, Nr Punam Pub School, Road No. 3,
Gudha Mode, Jhunjhunu, Rajasthan - 333001
42
ARUN SINGH
60 RAJESH ARYA
Vikram Singh Near R C Church,
Parbatpura, Ajmer, Rajasthan - 305001
S/o Prahalad Chand Arya, Ward No. 26, Colony
Badabas, Bansur Road, Kotputli, Jaipur Rajasthan
- 303108
43
SURENDRA KUMAWAT
61 UTKARSH SRIVASTAVA
104/22, Vijay Path, Mansarovar, Jaipur -
Rajasthan - 302020
A21, Rangoli Colony (Opp. New Sabji Mandi),
Sikandara , Agra, Uttar Pradesh-282007
44 ANIL KUMAR BALODIA 62 NARENDRA KUMAR
771, Sumer Nagar, Agarwal Farm,
Mansarowar, Jaipur, Rajasthan - 302020
D 190, Kolihan Nagar, Tehsil Khetri, Jhunjhunu ,
Rajasthan - 333503
45 ANIL KUMAR SAHU
63 NIRMAL CHAWLA
Indira Colony, Sawaimadhopur Road,
Apurva Collection - Tonk - Rajasthan -
304001
42 Mitra Vihar A Maharana Pratap Marg,
Panchyawala , Jaipur, Rajasthan - 302034
46 SUMIT KUMAR 64 DHANANAND TUKARAM CHANCHALKAR
House No. 107, Sarvjanik Gram Chok,
VPO- Nunia Gothara, Teh. Chirawa, Distt.
Jhunjhunu, Rajasthan - 333026
Siddharth Primary School, Nehrunagar,
Gyangboudi, Bijapur, Karnataka - 586101
47 RAJEEV RANJAN BHARTI 65 SUMIT KUMAR
S/o Ranjeet Kumar, MO - Mogalkuan Pops
- Sohshari Biharsharif , Nalanda - Bihar –
803108
H.No. 21/621 Ist Floor, Village - Karkardooma,
Delhi – 110092
48 JITENDRA KUMAR SAINI 66 GAGAN DEEP JEWARIYA
288, Main Village Bhandodi, V.P.O.
Bhandodi, VIA - Digavara, Alwar,
Rajasthan - 301414
114 Patel Nagar, Niwaru Road, Jhotwara, Jaipur,
Rajasthan - 302012
49 SUNIL KHILERI
67 PHOOL SINGH MAHAWAR
C/o Mohan Lal Khileri,Sadar Bazar,
Ladnun, Nagaur, Rajasthan - 341306
Vill-Meenapara, Post Manpur, Teh - Baswa,
Dausa, Rajasthan - 303509
50 AMIT KUMAR SONI 68 PANKAJ MEENA
Mangal Colony, Station Road,
Shrimadhopur, Distt. Sikar, Rajasthan -
332715
3/10 Ashok Vihar Colony, Narishala Road,
Subhash Nagar, Ajmer, Rajasthan - 305001
51 SANJAY KUMAR JANGID 69 LAXMI NARAYAN MEENA
Vishwakarma Bhawan, Near College Mode
Sethawali, Nathawala TH- Shahpura,
Jaipur , Rajasthan - 303103
Plot No. 1, Parwati Colony, Chetak Bhatte Ke
Samne, Goner Road, Luniyawas, Jaipur,
Rajasthan - 302031
52 NARENDRA SINGH CHAUHAN
70 KUSHAL DUBEY
A3, Shivram Colony, Near RLY Crossing,
Opp. PNB, Bank, Jagatpura - Jaipur -
Rajasthan 302017
Flat No. 18, Plot-42, Vandana Apt. Pratapganj, I.P.
Extn. Delhi - 110092
53 AWAD DAN
C/o Narayan Singh Roheria, 43, Roop
Nagar, Patoa C Road, Jodhpur -
Rajasthan - 342010
vuqizek.ku&i=
inuke % dj lgk;d
vuqizek.ku QkeZ esa dksbZ xyr lwpuk nsuk vFkok fdlh egRoiw.kZ
rF; dks Nqikuk v;ksX;rk le>h tk;sxh rFkk ;g vH;FkhZ dks ljdkjh lsok ds fy, v;ksX; djkj dj ldrh gSA ¼2½ D;k dHkh dkjkokl esa j[ks x,] U;k;ky; }kjk nks"kh fl) ik, x, vFkok fooZftr ?kksf"kr gq, gks rks mldk foLr`r fooj.k] bl QkeZ dks iw.kZ djus ds rFkk izLrqr djus ds i'pkr ml izkf/kdkjh ftlus ;g vuqizek.ku QkeZ Hkstk gS] mls 'kh?kz lwfpr dj nsuk pkfg,A lwpuk u nsus ij ;g le>k tk;sxk fd egRoiw.kZ rF; fNik;k x;k gSA
;fn fdlh O;fDr ds lsokdky ds nkSjku fdlh Hkh le; bl ckr dk irk py tkrk gS fd mlus vuqizek.ku QkeZ esa xyr lwpuk nh gS vFkok fdlh egRoiw.kZ rF; dks fNik;k gS rks mldh lsok,as lekIr dh tk ldsxhA uksV % uhps fn, x, izR;sd dkWye esa okafNr lwpuk iw.kZ :i ls fy[ksa] dksbZ Hkh dkWye [kkyh vFkok
¼&½ yxkdj u NksM+saA ¼1½ iwjk uke ¼lkQ v{kjksa esa½
¼;fn vkius dHkh fdlh le; vius uke vFkok dqyuke esa dksbZ va’k tksM+k gks vFkok mlesa ls gVk;k gks rks mldk mYys[k djsa½
%
¼2½ orZeku iwjk irk ¼ftleas xkWao] Fkkuk] ftyk] edku u0] xyh] lM+d] 'kgj rFkk ftyk eq[;ky; dk uke fn;k tk;s½
%
¼3½¼v½ LFkkbZ ?kj dk iwjk irk ¼ftleas xkWao] Fkkuk] ftyk] edku u0] xyh] lM+d] 'kgj rFkk ftyk eq[;ky; dk uke fn;k tk;s½
%
¼3½¼c½ ;fn ewy :i ls ikfdLrku ds fuoklh gSa rks ml ns'k esa mudk irk rFkk Hkkjr esa izotu dh frfFk
%
¼4½ jk"Vªh;rk % ------------------------------------------------------------------------------------- ¼5½ ¼v½ tUefrfFk % ¼c½ fnukad 01-01-2014 dks vk;q % ----------------- o"kZ ---------------- ekg ----------------- fnu
Lo;a dk gLrk{kfjr QksVks ¼ikliksVZ lkbZt½ ;gkWa fpidk;saA
¼jktif=r vf/kdkjh ls izekf.kr gks½
¼6½ xr ikWap o"kksZa esa tgkWa vkius ,d o"kZ ls vf/kd fuokl fd;k gS] ogkWa fuokl dh vof/k crkrs
gq, LFkkuksa dk fooj.k nsaA ;fn fons’k ¼ikfdLrku lfgr½ esa jgsa gksa] mu lc LFkkuksa dk fooj.k fn;k tkuk pkfg;s tgkWa vkius 21 o"kZ dh mez ds i'pkr ,d o"kZ ls vf/kd dh vof/k ds fy;s fuokl fd;k gksA
fnukad ls fnukad rd fuokl dk iwjk irk
¼vFkkZr xkWao] Fkkuk] ftyk] edku u0] xyh] lM+d] 'kgj vkfn½
fiNys dkWye esa fn, x, LFkku ds ftyk eq[;ky;
dk uke
¼7½ ikfjokfjd fooj.k % uke jk"Vªh;rk
tUe ls@ vf/kokl }kjk
dk;Z djus dk LFkku
O;olk; ¼;fn lsok esa gSa rks dk;kZy; dk irk o inuke nhft,½
orZeku Mkd dk irk ¼;fn e`r gS rks vkf[kjh irk½
¼1½ ¼2½ ¼3½ ¼4½ ¼5½ ¼1½ firk dk uke
¼miuke lfgr½
¼2½ ekrk ¼3½ iRuh@ifr ¼4½ HkkbZ
¼5½ cgusa
¼8½ ;fn iq= vkSj iqf=;kWa fons’k esa i<+ jgs gksa@jg jgsa gksa rks ml laca/k esa Hkh lwpuk izLrqr dh tk;sa % uke jk"Vªh;rk
¼tUe ls@ vf/kokl ls½
tUe LFkku iwjs irs lfgr ml ns'k dk uke tgkWa i<+ jgs gSa@jg jgsa gSaA
frfFk ftleas fiNys dkWye esa mYysf[kr ns'k esa jg@i<+ jgs gSa
¼9½ ¼v½ tUe LFkku %
ftyk rFkk jkT; ftlesa fLFkr gS %
¼c½ ftyk rFkk jkT; dk uke ftlds vki fuoklh gSa
¼l½ ml ftys rFkk jkT; dk uke % ftlesa vkids firk ewy :i ls lEc) gS
¼10½ ¼v½ /kEkZ
¼c½ D;k vki vuqlwfpr tkfr@vuqlwfpr tutkfr@ vks-ch-lh- ds lnL; gSa \ mRrj gkWa ;k uk esa nsa ;fn mRrj gkWa esa gS rks mldk uke crk;sa % gkWa@ugha -----------------------------------------------------
¼11½ 'kS{kf.kd ;ksX;rk % 15 o"kZ dh mez ds i'pkr Ldwyksa@dkWystksa esa tgkWa f’k{kk izkIr dh gS muds uke rFkk f’k{k.k o"kZ %
Ldwy dkWyst dk uke izos'k dh
frfFk NksM+us dh frfFk
mRrh.kZ dh xbZ ijh{kk
vadksa dk izfr’kr
¼12½ D;k vki fdlh dsUnzh; vFkok jkT; ljdkj vFkok v)Z ljdkjh vFkok ljdkjh o`r fudk;
vFkok fdlh Lok;Rr fudk; vFkok ifCyd v.MjVsfdax ¼lkoZtfud laxBu½ vFkok futh QeZ ;k laxBu esa fdlh in ij gSa] vFkok iwoZ esa ,sls in ij fu;qDr gq, Fks ;fn gkW rks fu;kstu dk v|ru frfFk;ksa lfgr iwjk fooj.k nhft, A
vof/k inuke] ifjyfC/k;kWa rFkk
fu;kstu dh izd`fr fu;kstu dk iwjk uke o irk
fiNyh ukSdjh NksM+us ds dkj.k
ls rd
¼13½ D;k fiNyk jkstxkj Hkkjr ljdkj@jkT; ljdkj@ljdkj }kjk fu;af=r vFkok futh
v.MjVsfdax@Lok;Rr fudk;@fo’ofo|ky;@LFkkuh; fudk; ds v/khu Fkk \ ;fn lfoZl NksM+h gS rks D;k vkius dsUnzh; flfoy lfoZl ¼vLFkkbZ lsok;sa½ fu;e 1965 ds fu;e 5 ds v/khu ,d ekg dk uksfVl fn;k Fkk vFkok blh rjg ds fu;eksa ds v/khu vkids fo:) fdlh izdkj dh vuq’kklukRed dk;Zokgh dh xbZ Fkh] vFkok lsok ls R;kxi= dk uksfVl nsrs le; vFkok okLrfod :i ls vkidh lsok;sa lekIr djus ds iwoZ vuqorhZ frfFk ij D;k vkidks fdlh Hkh ekeys esa vius vkpj.k dks Li"V djus ds fy, cqyk;k x;k Fkk \
¼14½ fuEufyf[kr izR;sd iz’u dk lqfuf’pr mRrj gkWa vFkok ugha tSlk Hkh ekeyk gks] dks iz’u ds
lkeus mYys[k djsaA ¼d½ D;k vki dHkh fxj¶rkj fd, x, gSa \ ¼[k½ D;k vkids fo:) dHkh vfHk;kstu pyk gS \ ¼x½ D;k vki dHkh utjcan fd, x, gSa \ ¼?k½ D;k vki ij dHkh U;k;ky; }kjk n.M yxk;k x;k \ ¼M-½ D;k vki dHkh u’ks esa /kqr ik, x, \ ¼p½ D;k vki dHkh fdlh U;k;ky; }kjk vijk/k ds fy, ¼fl)nks"kh½ Bgjk;s x;s \
¼N½ D;k vkidks la?k yksd lsok vk;ksx }kjk dHkh mudh ijh{kkvksa@p;uksa esa lfEefyr gksus ls vioftZr vFkok v;ksX; ?kksf"kr fd;k x;k \
¼t½ D;k vkidks fdlh ijh{kk esa csBus ls jksdk x;k vFkok fdlh fo’ofo|ky;@laLFkk }kjk fu"dkflr ¼jsLVhdsV½ fd;k x;k \
¼>½ bl vuqizek.ku QkeZ ds Hkjrs le; D;k fdlh U;k;ky; esa vkids fo:) dksbZ ekeyk cdk;k iM+k gS \
¼¥½ bl vuqizek.ku QkeZ ds Hkjrs le; D;k fdlh fo’ofo|ky; esa vFkok fdlh vU; 'kS{kf.kd izkf/kdkjh ds le{k vkids fo:) dksbZ ekeyk cdk;k iM+k gS \
;fn mijksDr iz’uksa dk mRrj gkWa esa gks rks ekeys ds fxj¶rkjh ds fo:) gksus ds@tqekZuk fd, tkus ds@dqdhZ gksus ds@n.Mkns’k fd, tkus ds@nf.Mr gksus vkfn ds iwjs fooj.k nsa vkSj@vFkok U;k;ky; esa@fo’ofo|ky; esa@’kS{kf.kd izkf/kdkjh ds le{k cdk;k iM+s ekeyksa dh izo`fr dk Hkh iw.kZ mYys[k djsaA
uksV % d`i;k bl vuqizek.ku QkeZ ds Åij nh xbZ psrkouh dks Hkh ns[ksaA ¼15½ vius bykds ds nks ftEesnkj O;fDr;ksa ds uke tks vkidks tkurs gksa % 1- ----------------------------------------------------------- 2- ----------------------------------------------------------- irk % irk % eSa izekf.kr djrk gwWa fd esjh tkudkjh vkSj fo’okl ds vuqlkj mi;qZDr lwpuk lgh vkSj iwjh gSA eq>s ,slh fdlh vkSj ckr dk Kku ugh gS tks ljdkj ds vUrxZr esjh fu;qfDr dh mi;qDrrk dks nwf"kr dj ldsaA vH;FkhZ ds gLrk{kj ----------------------------------------------- frfFk % LFkku %
¼izek.k&i= fuEufyf[kr esa ls fdlh ,d ds }kjk gLrk{kfjr fd;k tkos½ 1- dsUnz vFkok jkT; ljdkj ds jktif=r vf/kdkjhA 2- ml fo/kkulHkk {ks= ds izkFkhZ vFkok mlds ekrk&firk@laj{kd lkekU;r% jg jgk@jgsa gksa ds
fo/kkulHkk lnL; vFkok laln lnL;A 3- mi e.Myh; eftLVªsV@vf/kdkjhA 4- rglhynkj vFkok uk;c rglhynkj ftUgsa eftLVªsV dh 'kfDr;ksa ds iz;ksx ds fy, izkf/kd`r
fd;k x;k gksaA 5- tgkWa vH;FkhZ igys Nk= jg pqdk gks ,sls ekU;rk izkIr fo|ky;@egkfo|ky;@laLFkk ds
fizalhiy@iz/kkuk/;kidA 6- [k.M fodkl vf/kdkjhA 7- iksLV ekLVjA 8- iapk;r fujh{kdA izekf.kr fd;k tkrk gS fd eSa Jh@Jhefr@dqekjh -------------------------------------------------- iq=@iq=h@iRuh Jh -------------------------------------------------- dks fiNys -------------- o"kZ ------------- ekg ls tkurk gwWa rFkk muds }kjk fn, x, fooj.k esjh tkudkjh vkSj fo’okl ds vuqlkj lgh gSA LFkku % gLrk{kj % irk % ------------------------------------------------------------- uke o eqgj lfgr ------------------------------------------------------------- frfFk %
CERTIFICATE OF CHARACTER
Certified that I have known Shri ______________________________ S/o
Shri _________________________________ for the last __________ years
_________ months and that to the best of my knowledge and belief he bears
reputable character and has not antecedents which render him unsuitable for
Government Employment.
2. Shri ___________________________ is not related to me.
Place :________________ *Signature __________________
Date : _______________ Name & Designation __________
(* By a Gazetted Officer)
ATTESTED
Place :________________ **Signature : ________________
Date : _______________ Name & Designation :_______________
(Attesting Authority)
**(To be attested by Stipendiary I Class Executive Magistrate/ District Magistrate
or Sub Divisional Magistrate).
Phone No.2385021/025/007 Extn.232
FAX No. (0141) 2385222
Government of India
Ministry of Finance
Department of Revenue
OFFICE OF THE CHIEF COMMISSIONER
CENTRAL EXCISE (JAIPUR ZONE), JAIPUR (NEW CENTRAL REVENUE BUILDING, STATUE CIRCLE, C-SCHEME, JAIPUR-302005)
(CADRE CONTROL UNIT)
CANDIDATE STATEMENT AND DECLARATION CANDIDATE STATEMENT AND DECLARATION
The candidate must make the statement required below prior to his medical examination and must sign. the declaration appended thereto. His attention is specially directed to the warning contained in the note below:- 1 State Your Name in Full
(In block letters)
2 State your age and place of birth
3 a) Have you ever had smallpox, intermittent or any other fever, enlargement or suppuration of glands, spitting of blood, asthma, heart disease, lung disease fainting attacks rheumatism, append cities.
b) Any other disease or accident requiring confinement to bed and Medical or surgical treatment
4 When were you last vaccinated
5 Have you or any of your near relations have been affected with consumption scrofula, gout, asthma, fits, epilepsy or insanity
6 Have you suffered from any form of nervousness due to overwork or any other cause
7 Have you been examined and declared unfit for Govt. service by a Medical Officer/ Medical Board, within the last three years.
Contd. .......2/-
:: 2 ::
8 Furnish the following particulars concerning family:-
Father's age if living and state of health
Fathers age at death and cause of death
No. of brothers living their ages and state of health
No. of brothers dead their ages at death and cause of death
1 2 3 4
Mother's age if living and state of health
Mother's age at death and cause of death
No. of Sisters living their ages and state of health
No. of Sisters dead their ages at death and cause of death
5 6 7 8
I declare all the above answers to be, to the best of my belief, true and correct.
I also solemnly affirm that I have not received disability certificate/pension on account of any disease or other condition.
Candidate's signature
Signed in my presence
Signature of Medical Officer
NOTE:- The candidate shall be held responsible for the accuracy of the above
statement. By willfully suppressing any information be will incur the risk of losing the appointment and if appointed, forfeiting all claim to superannuation allowance of gratuity.
Annexure - “A”
Details of residential addresses for the last five years- S. No.
Date from Date to Complete Address of residence District Hqrs.
Signature of the candidate-------------------------------------
Name of the candidate------------------------------------------
Date------------------------------------------------------------------
Father’s name- ---------------------------------------------------
Address for correspondence----------------------------------
----------------------------------
----------------------------------
----------------------------------
Contact Phone No.-----------------------------------------------