SPECIAL SECURITY QUESTIONNAIRE

(To be adopted for re-verification)

Name:
Passport
size
photograph
Service No.

Appointment held

Office:
(Complete official address)

1. Employees should ensure that the information required against each heading is fully and
correctly given.

2. If it comes to the notice at any time subsequently that false information has been furnished or
that there has been a suppression of factual information in this form, his services will be liable
to be terminated solely on this ground.

Surname Forename
3. (a) Name in full

(b) Aliases (if any)

(c) Name at birth, if different and any other names,

surnames used at any stage.

4. Address:

(i) Present Address:

(a) House No./Name

(b) Locality/Street

(d) Town/Village

(e) Police Station

(f) Post Office

(g) District

(h) State

(ii) Permanent Home address:

(a) House No./Name

(b) Locality/Street

(c) Town/Village
 (d) Police Station

(e) Post Office

(f) District

(g) State

(iii) If originally a resident of a country other than India?:

(1) Address in the foreign country:

(a) Name of country (e) Police Station

(b) House No./Name (f) Post Office

(c) Locality/Street (g) District

(d) Town/Village etc.

(2) Date of entry to India

(3) Check post or point of entry

(4) Particulars of travel documents:

5. Phone/Mobile number registered in the name of officer and used by him:

…………………………………………

6. E.mail ID for communication:

………………………………………………………………………………………

7. Registration no. of personal vehicle being used by the officer:

………………………………………..

8. Active Bank Account No: . …………………………………………

9. PAN No. ………………………………………………………………………………….

10. Personal Passport No.……………………………

Validity upto……………………………………

11. (a) Date of birth (b) Place of birth

(c) District (d) State

(d) Country

12. (a) Nationality-

 (b) Religion-

13. (a) Particulars of places (with periods of residence) where you have resided for more that
one year at a time during the preceding three years:

From To Full address including Village, Police Station, Post Office,

Town, House & Street Number, etc.

(b) If you have stayed abroad, give particulars of all places where you have resided for more
than one year after attaining the age of 18 (Eighteen) years:-
From To Full particulars including Village, Reasons for
Police Station, District, Town, visit/residence
House and Street Number, Name
of the Country etc.

14. Have you ever had personal contact with an official of a

foreign country other than as a result of official duties?
If yes, give details.

15. i) If applicable, please give full name, date and place of

birth and occupation of spouse(including de facto spouse).

ii)Has this person (spouse) visited or resided in any overseas

country or are his or her relatives residing overseas?
If yes, please give details.

16. (i) Have you any other person over 18 years residing with you?
If yes, please give details, regarding name in full, date
and place of birth, relationship and occupation.

(ii) Has any person over 18 years residing with you, visited
or resided in overseas countries? If yes, please give details.

17. Give details, if you have ever been:

 (a) Arrested

(b) Prosecuted

(c) Kept under detention

(d) Charged before a Court with an offence for which you were
Convicted, conditionally discharged, placed on probation or
bound over or acquitted?

(e) Debarred or disqualified by any Public Service Commission

for any of its examinations/selections?

(f) Debarred from taking any examination or rusticated by any University?

(g) Discharged or dismissed from any employment?

(h) Whether discharged/expelled/withdrawn from any training

institution under the Government or otherwise?

18. Has any criminal case been registered against

you in which you may/may not have been arrested,
charge sheeted or detained?

19. Is any case or enquiry pending against you in any

Court of Law (including Civil Litigation) or any other
authority e.g. departmental proceedings etc.?
20. Have you ever been a prisoner of war or held in enemy
country for any duration? If so, give details.

21. Are you an arms licence holder? If so, give details of

licence and arms in possession.

22. Particulars of close relatives:

Name Nationality Place/ Occupation (if Present Permanent
(by birth or Country employed give Postal Home
by and date designation and address (if address
official address) dead give
domicile) of birth
last home
address)
(1) (2) (3) (4) (5) (6)
(a) Father

(b) Mother

(c) Wife/
Husband

(d) Son(s)

(e)daughter(
s)
(f) Brother(s)

(g) Sister(s)

(h)Step-
Son(s)

(i)Step-
Daughter(s)

23. (i) Particulars of relatives (Indian and Non-Indian) working in (a) Foreign Missions
and (b) Foreign Organizations including foreign concerns:
Name(s) Nationality Occupation ( (if Present Permanent
employed, give Residential address
designation and address
official address)

(ii) Do you have any relatives (including children) living overseas? If yes, please give the
following details of each one:-
Name(s) in full Relationship Country of residence Date(s)
with address(s)

24. (a) Have you been a member of any cultural or social

 organization which is associated with or assisted by Yes/No
foreign Mission or organization?

(b) Are you aware whether any of your relatives mentioned

in column No. 22 has been a member of any cultural or Yes/No
social organization which is associated with or assisted
by a Foreign Mission or Organization?

(c) Are you or have been a member of any Club/Society and/or

other such bodies? Yes/No

If the answer to (a), (b) and (c) or any of them is ‘YES’ give
following details:

(a) Name of the Organization/Club/Society etc.

(b) Name of the office Bearers

(c) Period of membership

(d) Details of any post/office held

(e) Whether still active or not?

(f) Reasons for relinquishing membership

(g) Any other relevant details

25. (a) Have you ever been a member/worker of any political party/ Yes/No
organization or participated in any political activities?

(b) Are you aware if any of your relatives mentioned in column Yes/No
No. 22 has ever been or continues to be a member/worker of any
political party/organization or ever participated in any
political activity?

If the answer to (a) and/or (b) is ‘YES’ give the following details:

Particula Name of Particulars Period of Nature of Particular

rs of Political Party/ of political membership participation s of Office
relatives Organization activity. of political in political if any,
(name/ party/org. or activity held in
Relation) participation political
in political party.
activity

(c)Have your or any of your relative mentioned in column No. 22 been a member/worker
of any Social/Political/Religious/Service Orgn../Union/Club?

If so, details thereof may be given below:

Organization Place Year Status
26. Have you or your wife any debts or outstanding loans?
If so, give details.

Note: (i) Acceptance of purely temporary loan of small amount free

of interest from a relative or personal friend, or operating
a credit account with a bonafide tradesman shall not be
treated as debt/loan under this column.

(ii) No details will be necessary in respect of any loan obtained

with the previous sanction of the Government.

27. State source of your income and that of the members of your family,
giving all details.

28. Mention details of movable/immovable property including agricultural

land etc. in your wife’s/husband’s name.

29. I have read and understood the Provisions of Paras 26 (i) and (ii).

30. 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 the candidate)

Place…………………

Date…………………. Name in full………………………….

 lR;kiu izi=
ATTESTATION FORM

psrkouh
WARNING
IkkliksVZ vkdkj ¼yxHkx 5 l-seh-x 7 l-seh-½
1. bl lR;kiu izi= esa xyr lwpuk Hkjuk vFkok okLrfod rF; Nqik, tkus dh ,d v|ru gLrk{kfjr QksVks izfr
;gka fpidk,aA
dks v;ksX;rk ekuk tk;sxk rFkk rnuqlkj vH;FkhZ dks ljdkjh ukSdjh ds fy,
vuqi;qDr ?kksf’kr fd;k tk ldrk gSA
Affix signed passport size (5 CM x 7 CM
The furnishing of false information or suppression of any approx) copy of recent photograph.
factual Information in the Attestation form would be a
disqualification, and is likely to render the candidate unfit
for employment under the Government.

2. ;fn bl izi= dks iwjk djus o izLrqr fd, tkus ds ckn vH;FkhZ dks gokykr esa Mkyk x;k gks] fxj¶rkj fd;k x;k gks] ml
ij eqdnek pyk;k x;k gks] ml ij vFkZn.M yxk;k x;k gks] ml ij dksbZ nk’s kkjksi.k fd;k gks] cfg’d`r fd;k x;k gks
vFkok mls nk’s keqDr vkfn fd;k x;k gks rks bl vk”k; dh lwpuk rRdky ml vf/kdkjh dks Hksth tk,] ftls ;g lR;kiu
izi= Hkstk x;k gSA ,slk u fd, tkus ij ;g ekuk tk,xk fd vH;FkhZ okLrfod rF; Nqik jgk gSA
If detained, arrested, prosecuted, bound down, fined, convicted, debarred, acquitted, etc. subsequent
to the completion and sub-
mission 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. ;fn O;fDr dh lsok ds nkSjku fdlh Hkh le; ;g irk pyrk gS fd mlus lR;kiu izi= esa dksbZ xyr lwpuk Hkjh gS
vFkok okLrfod rF;ksa dks Nqik;k gS] rks mldh lsok,a lekIr dh tk ldrh gSaA
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 services would be liable to be TERMINATED.

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1. miukeksa lfgr] ;fn dksbZ gks iwjk uke ¼;fn vkius dHkh vius uke dqyuke
vFkok] dqyuke esa va”kr% dqN tksM+k vFkok fudkyk gks rks mls SURNAME
fofufn’ZV djsa½A

Name in full (in BLOCK CAPITALS) with aliases, if any. (Please indicate uke
You have added or dropped in any stage any part of your name or surname) NAME
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2. orZeku iwjk irk vFkkZr~ xkao] Fkkuk rFkk ftyk vFkok edku u-a] xyh@ LVªhV@lM+d rFkk “kgj

Present Address in full (i.e., Village, Thana and District, or House Num-
ber, Lane/Street/Road and Town.

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3. ¼d½ ?kj dk iwjk irk ¼vFkkZr~ xkao] Fkkuk rFkk ftyk vFkok edku u-a] xyh@ LVªhV@lM+d o “kgj½ vkSj ftyk eq[;ky; dk
uke
(a) Home Address in full (i.e., Village, Thana and District or House Num- ber, Lane/Street/Road
and Town and name of District Headquarters.
¼[k½ ;fn ewyr% ikfdLrku@caxyk n”sk ¼iwoZ iwohZ ikfdLrku dk fuoklh gS rks ml n”sk esa jgus dk irk rFkk ogka ls Hkkjr vkus
dhs rkjh[k dk mYys[k djs½a A
(b)If originally a resident of Pakistan/Bangladesh (erst-while East Pakis- tan the address in that
country and the date of migration to Indian Union.)
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 2

4. xr ikap o’kksZa ds nkSjku mu LFkkuksa ds C;kSjs nsa ¼vkokl&vof/k lfgr½ tgka vkius ,d le; eas ,d o’kZ ls vf/kd vof/k ds
fy, fuokl fd;k gksA 21 o’kZ dh vk;q izkIr djus ds ckn ;fn vkius ikfdLrku lfgr vU; n”s kksa esa ,d o’kZ ls vf/kd
ds fy, fuokl fd;k gks rks mu lHkh LFkkuksa ds Hkh C;kSjs izLrqr djsaA
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.

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ls rd vkokl dk iwjk irk ¼vFkkZr~] xkao] Fkkuk iwoZ dkWye esa mfYyf[kr LFkku ds
rFkk ftyk vFkok edku xyh@LVªhV@ ftyk eq[;ky; dk uke
u-a
 lM+d rFkk “kgj½
From To Residential address in full (i.e. Village, Name of the
Thana and Dist. or House No. Lane/ District Headquarters of
Street/Road and Town) the place mentioned
in
the preceding column.
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1 2 3 4
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5. uke jk’Vªh;rk ¼tUe tUe LFkku O;olk; ¼;fn i=kpkj dk ?kj dk LFkkbZ
vkSj@vFkok lsokjr gSa rks orZeku irk irk
vf/kokl }kjk½ inuke o dk;kZ& ¼fnoaxr gksus dh dk irk fy[ksa½
fLFkfr eas vafre
irk½
Name Nationality (by Place of birth Occupation (if Present Postal
Permanent Home Birth and/or by employed
give address (if dead Address
domicile) designation and give last address)
Official address)
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1 2 3 4 5 6

¼d½ firk ¼miukeksa lfgr ;fn dksbZ gks½

(a) Father (Name in full aliases, if any).

¼[k½ ekrk
(b) Mother

¼x½ iRuh@ifr
(c) Wife/Husband

¼?k½ HkkbZ
(d) Brother(s)

¼M½ cgu@cgusa
(e) Sister(s)
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5. ¼d½ ml iq=@iq=ksa vkSj iq=h@iqf=;ksa ds ckjs esa lwpuk nsa tks fon”sk esa i<+ jgs@jg jgs gSa%&
(a) Information to be furnished with regard to son(s) and/or daughter(s) in case they are
studying/living in a FOREIGN COUNTRY:-
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uke jk’Vªh;rk ¼tUe tUe LFkku ftl n”sk esa iwoZ dkWye esa mfYyf[kr
vkSj@vFkok Ik<+ jgs@jg jgs n”sk esa dc ls i<+ jgs@
  vf/kokl }kjk½ gSa] mldk iwjk irk jg jgs gSa
Name Nationality (by birth Place of birth Country in which Date from which
and/or by domicile) studying/living with studying/living
in full address the country men-
 tioned in previous
column
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1 2 3 4 5
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6. jk’Vªh;rk
NATIOANLITY
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7. ¼d½ tUe frfFk ¼d½
(a) Date of birth (a)
¼[k½ orZeku vk;q ¼[k½
(b) Present Age (b)
¼x½ eSVªhdqys”ku ds izek.k&i= esa nh xbZ vk;q ¼x½
(c) Age at Matriculation (c)
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8. ¼d½ ftys o jkT; dk uke lfgr tUe LFkku ¼d½
(a) Place of birth, District and State in which situated (a)

¼[k½ vki fdl ftys o jkT; ls lEc) gSaA ¼[k½

(b) District and State to which you belong (b)
¼x½ vkids firk ewyr% fdl ftys o jkT; ls lEc) gSaA ¼x½
(c) District and State to which your father originally belong (c)
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9. ¼d½ vkidk /keZ
(a) Your religion

¼[k½ D;k vki vuqlwfpr tkfr ;k vuqlwfpr tutkfr@

vU; fiNM+h tkfr ls lEc) ftlls lEc) gksa] mldk
g\Sa
uke fy[ksaA
(b) Are you a member of Scheduled Caste/Scheduled Tribe/OBC?
If answer is ‘Yes’, state the name thereof.
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 4

10. 15 o’kZ dhs vk;q ls ftu Ldwyksa o dkWfytksa esa f”k{kk izkIr dh gS] rkjh[k lfgr mudk mYys[k djrs gq, “kS{kf.kd ;ksX;rk fy[ksaA
Educational qualification showing places of education with years in Schools and Colleges since 15th year of
age.
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iwjs irs lfgr Ldwyksa@dkWfytksa Ldwy@dkWfyt esa Ldwy@dkWfyt NksM+us dkSu lh ijh{kk
ds uke izos”k dh rkjh[k dh rkjh[k ikl dh
Name of School/Colleges with Date of entering Date of leaving Examination passed
Full address
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11. ¼d½ D;k vki dsUnz vFkok jkT; ljdkj vFkok v/kZ ljdkjh vFkok v/kZ ljdkjh fudk;] vFkok Lok;Ÿk fudk; vFkok
yksd
miØe vFkok futh QeZ vFkok laLFkku esa lsokjr gSa vFkok lsokjr jg pqds g\Sa ;fn gks rks lsok dh rkjh[kksa lfgr iw.kZ
v|ru C;kSjk nsaA
(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, upto date.
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vof/k inuke] osru rFkk lsok fu;ksDrk dk iwjk iwoZ lsok
PERIOD dh izo`fŸk uke o irk NksM+us ds dkj.k
----------------------------------------
ls rd Designation, emoluments Full name & address of Reasons for leaving
FROM TO & nature of employment employer previous service
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11. ¼[k½ D;k fiNyh lsok Hkkjr ljdkj] jkT; ljdkj@fdlh
miØe ds LokfeRok/khu vFkok Hkkjr ljdkj vFkok jkT; ljdkj@Lok;Rr fudk;@fo”ofo|ky;@LFkkuh; fudk; ds
fu;U=.kk/khu FkhA
(B) If the pervious employment was under the Government of India, a State Government/an
Undertaking owned or controlled by the Government of India or a State Govern- ment/an
Autonomous Body/University/Local Body.
D;k vkius dsUnzh; flfoy lsok ¼vLFkkbZ lsok½ fu;ekoyh]
1965 vFkok blds vuq#i fu;ekoyh ds rgr ,d ekg ds uksfVl ij lsok NksM+h Fkh\ D;k vkids fo#)
dksbZ
vu”qkklukRed dkjZokbZ dh xbZ D;k uksfVl fn, tkus
g\S
vFkok lsok lekIr fd, tkus ds le; vFkok okLrfod #i
esa vkidh lsok,a lekIr fd, tkus ds iwoZ] ckn dh rkjh[k esa vkils Li’Vhdj.k ekaxk x;k\
If you had left service on giving a month’s notice under Rules 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 or termination of service, or at a subsequent date, before
your services actually terminated?
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 5
12. (i) ¼d½ D;k vkidks dHkh fxj¶rkj fd;k x;k g\S gka@ugha
(a) Have you ever been arrested? Yes/No
¼[k½ D;k dHkh vki ij eqdnek pyk gka@ugha
g\S
(b) Have you ever been prosecuted? Yes/No
¼x½ D;k dHkh vkidks fgjklr esa j[kk x;k g\S gka@ugha
(c) Have you ever been kept under detention? Yes/No
¼?k½ D;k dHkh vkidks utjcUn fd;k x;k g\S gka@ugha
(d) Have you ever been bound down? Yes/No
¼M½ D;k fdlh fof/k&U;k;ky; us vki ij dHkh vFkZn.M Mkyk g\S gka@ugha
 6

(e) Have you ever been fined by a Court of Law? Yes/No

¼p½ D;k dHkh fdlh fof/k&U;k;ky; us fdlh vijk/k ds fy, vkidks gka@ugha nk’skh fl) fd;k g\S
(f) Have you ever been convicted by a Court of Law for any Yes/No offence?
¼N½ D;k dHkh fdlh fo”ofo|ky; vFkok fdlh vU; “kS{kf.kd gka@ugha izkf/kdj.k laLFkku us vkidks
fdlh ijh{kk esa cSBus ls jksdk gS
vFkok cfg’d`r fd;k g\S
(g) Have you ever been debarred from any examination or rusticated Yes/No by any
University or any other educational authority/institution?
¼t½ D;k dHkh fdlh yksd lsok vk;ksx@deZpkjh p;u vk;ksx us gka@ugha viuh fdlh ijh{kk@p;u ls
vkidks cfg’d`r@v;ksX;
?kksf’kr fd;k g\S
(h) Have you ever been debarred/disqualified by any Public Service Yes/No
Commission/Staff Selection Commission for any of its Examina-
tion/Selection ?

¼>½ D;k og lR;kiu izi= Hkjuss ds le; fdlh fof/k&U;k;ky; esa gka@ugha vkids fo#) dksbZ eqdnek
yfEcr g\S
(i) Is any case pending against you in any Court of Law at the time Yes/No of filling up this
Attestation Form?
¼¥½ D;k og lR;kiu izi= Hkjrs le; fdlh fo”ofo|ky; vFkok gka@ugha vU; “kS{kf.kd izkf/kdj.k@laLFkku
esa vkids fo#) dksbZ ekeyk
yfEcr g\S
(j) Is any case pending against you in any University or any other Yes/No educational
authority/Institution at the time of filling up this
Attestation Form?

¼V½ D;k ljdkj ds fu;U=.kk/khu vFkok vU; fdlh izf”k{k.k laLFkku gka@ugha ls vkidks dk;ZeqDr fd;k
x;k@cfg’d`r fd;k x;k@fudkyk
x;k\
(k) Whether discharged/expelled/withdrawn from any training ins-
titution under the Government or otherwise? Yes/No

(ii) ;fn ;g izi= Hkjrs le; mijksDr i”zuksa dk ÞmÙkjß gka gS rks ml
eqdnes@fxj¶rkjh@fgjklr@vFkZn.M@n.Mkns;@ltk vkfn ds ckjs esa vkSj@vFkok fdlh
U;k;ky;@fo”ofo|ky;@ “kS{kf.kd izkf/kdj.k vkfn esa yfEcr eqdnes dh izd`fr ds iw.kZ C;kSjs nsaA
If the answer to any of the above mentioned 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.
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UkksV%& (i) d`Ik;k bl izi= ds ÞizkjEHkß esa fy[kh Þpsrkouhß dks Hkh ns[ksa A
NOTE: Please also see the “WARNING” at the top of this Attestation Form.
(ii) IkzR;sd iz”u dk fof”k’V mÙkj Þgkaß vFkok Þughaß tSlk Hkh ekeyk gks] dkV dj fn;k tk,A
Specific answers to each of the questions should be given by striking out ‘Yes’ or ‘No’ as
the case may be.
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13. vIkus {ks= ds ,sls nks O;fDr;ksa ds uke vFkok gokys fy[ksa] tks vkidks tkurs gksaA
Names of two responsible persons of your locality or two references to whom you are known.

6
 7

1.

2.

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eSa lR;fu’Bk ls ?kksf’kr djrk@djrh gwa fd esjs ek= ,d thfor iRuh@ifr gSA
I solemnly declare that I have not got more than One Wife/Husband living.

eSa izekf.kr djrk@djrh gwa fd esjh tkudkjh rFkk fo”okl ds vuqlkj mijksDr lwpuk lgh rFkk iw.kZ gSA eSa
fdUgha ,slh ifjfLFkfr;ksa ls voxr ugha ftlds rgr eSa ljdkjh ukSdjh ds v;ksX; ekuk@ekuh tkÅa A

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.

vH;FkhZ ds gLrk{kj --------------------------------------------

Signature of Candidate

Rkkjh[k -----------------------------------------------------------------
Date

LFkku ------------------------------------------------------------------
Place

7
 8

igpku izek.k&i=
IDENTITY CERTIFICATE

¼izek.k&i= ij fuEu esa ls fdlh ,d ds }kjk gLrk{kj fd, tk,a ½

(Certificate to be signed by any one of the following)

1. dsUnz vFkok jkT; ljdkj ds jktif=r vf/kdkjh A

Gazetted Officers of Central or State Government.

2. ml fuokZpu {ks= ds lkaln vFkok fo/kk;d tgka vH;FkhZ vFkok mlds ekrk&firk@vfHkHkkod LFkkbZ rkSj ij jgrs gSaA
Members of Parliament or State Legislature belonging to the constituency where the candidate or his
parent/guardian is ordinarily resident.

3. mi&izHkkxh; eftLVªsV@vf/kdkjhA
Sub-Divisional Magistrate/Officers.

4. eSftLVsfj;y “kfDr;ksa ds fy, izkf/kd`r rglhynkj vFkok uk;c mi rglhynkjA

Tehsildars or Naib/Deputy Tehsildars Authorised to exercise magisterial powers.

5. ml ekU;rk izkIr Ldwy@dkWfyt@laLFkk ds iz/kkukpk;Z@gSMekLVj tgka vH;FkhZ us viuh i<+kbZ lekIr dh gksA
Principal/Head Master of the recognized School/College/Institution where the candidate studied last.

6. [k.M fodkl vf/kdkjhA

Block Development Officer.

7. iksLV ekLVjA
Post Masters.

8. iapk;r fujh{kdA
Panchayat Inspectors.

izekf.kr fd;k tkrk gS fd eSa Jh@Jhefr@dqekjh ------------------------------------------------------------------------------------------------------------------------------------------- iq=@iq=h

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fiNys------------------------------------------------------------------------o’kk-sZa--------------------------------------------eghuksa ls tkurk gwa vkSj esjh tkudkjh o fo”okl ds vuqlkj
muds }kjk Hkjs x, C;kSjs lgh gSaA
Certified that I have known Shri/Smt./Kumari son/daughter
of Shri for the last years
months and that to the best of my knowledge and belief the
particulars furnished by him/her are correct.

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Date Signature

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Place Designation or Status and
Address.

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TO BE FILLED BY THE OFFICE

(i) fu;qfDr djus okys izkf/kdkjh dk uke] inuke rFkk iwjk irkA
Name, designation and full address of the appointing authority.

(ii) vH;FkhZ }kjk vkosnu fd;k x;k og i=] ftl ij fu;qfDr gsrq fopkj fd;k tk jgk gSA
Post for which the candidate is being considered