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ATTESTATION FORM

Candidate for the post of :- Name in full in Block CAPITAL with aliases, Surname NameIf any-(Please indicate if you have added or dropped atAny stage any part of your name or surname).2. Present address in full (i.e. village, Thana, andDistrict or House No. Land/Street and Road).

Home address in full (i.e. village, ThanaDistrict or House No. Land/Street and Road),

if originally a resident of Pakistan and addressIn that Dominion and the date of Migration toIndian Union.4. Particular of places where you have resided forMore than one year during the preceding five year.From to Residential address in full (i.e village,Thana and District or HouseNo Lane Street andRoad.)

5. Father's (a) Name in full with aliases, if any, (a)Present postal address (if dead, give last (b )address)Permanent Home addressProfessionif in service, give designation and officialAddress6. (i ) Nationality of :-Father (a)Mother (b)Husband (c )Wife (d )(ii) Place of Birth of :-Husband (a)Wife (b)

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7. (a) Exact date of birth as given in the (a)Matriculation Pass Certificate.Present Age (b )Age at Matriculation (c)(d) Mark of Identification (d)8 . (a) Place of Birth, district and State in which it (a)Is situated.District and State to which you belong (b )District and State in which properly is held (c)

(a) Are you a member of a Scheduled Caste or (a )Scheduled Tribes/Backward Class of HaryanaAnswer Yes or No and if the answer is Yes stateThe name thereof-(b ) if Member of Scheduled Caste, state your religion (b)/Caste, if member of Backward Class, state yourCaste.Educational qualification showing places of educationwith years in school and colleges since 15 th year of age.

Name of School/College Date of Date of Examination with full address. Entering leaving passedIf you have, at any time been employed, give details:-Designation of post held or description Period Full address ofthe of work. From to office, firm orinstitutionAre you an Ex-ECO, Ex-JCO or Ex-Serviceman orOr likely to be released ? if so, State the rank(i) Officer (ii) Junior Commissioner Officer; and(iii) Other Rank besides indicating the date of entryand release in the army.

13 . Have you ever been convicted by Court of anyOffence? If the answer is 'Yes' the full Particulars

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of the convictions and the sentences, should be given

Name of two responsible persons of your locality or twoReferences to-whom you are known with full address.

Are you married ? If so, please state number ofliving wives you have.(This information is to be given by male persons only)

I Certify that the foregoing information is correct and complete to the best of myknowledge and belief, I am not aware of any circumstances which might impair myfitness for employment under Government.

Signature of the CandidateDatePlace

(Certificate to be signed by a Gazetted officer or member of legislature or otherauthority prescribed by the appointing authority)

Certified that I have known Shri/ Shrimati/ Kumaridaughter of Shri for the last years months and that tothe best of my knowledge and belief the particulars furnished by him/her are correct.

Place SignatureDate (Designation of Status and Address)ADDRESS in CAPITAL words on which theCandidate desires further intimation