fx signed passport size (Sem.x7 em approx) copy of recent photograph where asked for ANNEXURE-1 ATTESTATION FORM 2 “ WARNING” ‘The furnishing of false information or suppression of any factual information in the Attestation form would be 2 squalifiation, and is kely to render the candidate unfit for employment under the Government, If éetained, arrested, prosecuted, bound down, fined, convicted, debarred, acquitted etc. subsequent to the completion and submission of this form, the details should be communicated immediately to the authorities ta whom the attestation form hae been sent early, fling which ft wil be deemed to be a suppression of factual information HE the fact that false information has been furnished or that there has been suppressions of any. factual Information in the attestation form comes to notice at any time curing the service ofa person, his services would be lable tobe terminated” T_ Name in fal in Block capital with aliases, if any, (Please indicate If you have added or droppee in any stage any part cof your name or surname, [& Present Adcress in full Ge} Village, Thana and District or House ‘Number, lane/ Street Roae and Town}, “SURNAME TAME 3. (a) Home Agarose ih Tal We Village, thana, and Disret or House Number, Lane Street / Rae and Town and name of District Headquarters, Tif orginally a vescent oF Pakisan/ Bangladesh (erstwhile East Pakistan) the laderess in that country and the date of mi jonto indian4. Particulars of places (with petlos, of residences) where you have resided for more than one year at a time during the preceding five years. In case of stay abroae (including Pakistan) particulars ofall places where you have resided for mre than one year after attaining the age (of 21 years, should be given From Te Residential addresses In] Wame of the Dietiet full (ie, Vilage, Thana | Headquarters of the place and Dist. of House No, | mentioned in the preceding Lane / Street Road and | column Name Nationality Place of Occupation Present Permanent (by birth bith (if postal Home: and/ or by employed address if address domicile) give desig- desc, give nation & last official address) address) (0 Father (Name in fulaliases, if any. (ip Mother (ii) witephusband (i) Brother's) (uy sisters)5. (a) Information to be furnished with regard to sons(s) and or daughters) In case they are studying/ living na foreign county Name Nationality | Place ofbinh | Country in which | Date ror which (oy bith studying living with | studying living in the andor by full acdress country mentioned domicile) . Nationalify 7 Ta) Date oF bh o) TB) Present Age my Te Rae at areuTaion a) Pace of bith, Daa and State | Ta) hich situated {by Distsiek and State to which you belong. | (0) Te) Disiet and Sate to whieh your Tather originally belong. 9. Tay Your relajon TW) Ave you 8 ember of a Scheduled Caste/Scheduled Tribe? Answer "Yes or Not 10, Educational Qualification showing places of education with years in Schools and Colleges since 15° ‘Year of age ‘Name of School/Gollege | Date of entering] Date ofleaving | Bamination passed with ull aderess11,14) Are you holding or have any time held an appointment under the Cental or State Government oF 2 SemisGovernment oF a QuashGovernment body, or an autonomous body, oF a public undertaking, 0a private firm oF in tution ? 1750, eve ful particulars with dates of employment, upto-ate Period Designation, |Full name and] Ressons Tor emoluments and address of | leaving previous From To nature of | employer server. employment 12,(B) if the previous employment was under the Government of India, 2 State Government/an Undertaking owned or controlled by the Government of India or a State Government/an autonomous Body/University/Local Body. IF you had left service on giving 2 month’s notice under Rule 5 of the Central Chl Services (Temporary Service) Rules, 1965, or any similar corresponding cules, were any disciplinary proceedings framed against you, or had you been called upon to explain your conduct in any matter a the time you gave notice of termination of service, oF ata subsequent date, before your services actually terminated? "TE (a) Have you eve" bean arrested ? Yes7No Tay Have you ever been prosecuted? YesTNo Te) Have your ever been Kept under detention YesTNo (a) Have you ever been baund down? Yes Ne Te] Have you ever been fined bya Court of Law? Yano GH Have you ever been convicted by a Court oF law for any | Yeu) No offence? 1 Have you ever been debared from any examination oF | Yeu! NoTustcated by any Unversity oF any other educational authorityinstitution? TH) Have you ever been debarred/ dsquallied by any Public | Yeu] No Service Commission/Sttt Selection Commission for any ofits examination selection? Uy i any case pending aganst you Tn any Court of Law atthe | Yeu No time of filing up tis Attestation Form? Ty any case pending against you In any University or any | Ves7 No ‘other ecucstional authorityinsttution at the time of filing up this Attestation Form? TW) Whether acharged/oxpeliec/witharawn from any Wain | Yeu/No Instuion under the Government or otherwise ? Ti the answer To any ofthe above mentioned question is Yew, five full particulars of the case/ artest/ detenton/ fne/ conviction sentence/ punishment etc. andr the nature of the case pending in the Court/ University/Educational Authority et. atthe time of iling up this ferm, NOTE: (i) Please also see the ‘warning’ at che top ofthis Attestation Form, (i) Specific answers 19 each ofthe questions shoula be given by striking out “Yes! or ‘No’ asthe case may be, TB. Names of two responsible persons of your | L locality or two references to whom you | certify thatthe foregoing information is correct and complete to the best of my knowledge and belief. lam not aware of any circumstances which might impair my fitness for employment under Government Signature of candidate. bate laceIDENTITY CERTIFICATE (Cette © tobe signed by any one ofthe following) (i) Gazetted officers of Contra or State Government: (i) Members of Parliament or State Legislature belonging tothe constituency where the candidate or his parent/ guardians ordinary resident: (ii) Sub-Divisional Magisrate/Otfcers; liv) Tensitdars or Naib/Deputy Tehs drs authorized to exercise magisterial powers (0) Princpa/Head-Master ofthe recognised School/College/Institution where the candidate stucled last (i) Block Develoor (vi) Post Masters nt officer; (vil) Panchayat Inspectors Certified that | have known Shri/Sm/Kumar, Son/daughter of Shr for the as. years sonths and that to the best of my knowledge and belle the particulars furnished by him/her ae correct. Date, Signature Place Designation or status and aderess TO BE FILLED BY THE OFFICE (i) Name, designation and full address ofthe appointing authority. (i) Post for which the candidate is being consideredAnnexure} CERTIFICATE OF CHARACTER Ccertfied that | have known Shri/Smt/kum, son daughter of Shrismt forthe last__ years ‘months and | consider him ‘hr suitable for aapointment as in the Food Corporation of india, So far as | know, there is nothing adverse In his / her character and antecedents or previous work which mekes him/her unsuitable for appointment Lam not related to him / her Place Signature ate Designation Occupation address To be attested by: For tegory Il posts District Magistrate ora Sub-Divisonal Magistrate or thelr superior officers For Category—IV posts: Gazetted Oficer or a MagistrateAnnexure ~ IIL DECLARATION 1, Shri/Smt, kum. declare as under :~ (2) That I am unmarried/ a widower/ a widow. (b) That I am married and have only one wife living, (©) That I am married and my husband has no other living wife to the best of my knowledge, (d)That Iam married and have more than one wife living. (Application for grant of exemption is enclosed.) (e) That am married to a person who have already one wife or more living. (Application for grant of exemption is enclosed.) solemnly affirm that the above declaration is true and I understand that in the event of the declaration being found to be incorrect after my appointment, I shall be liable to be dismissed from service. (Signature) Dated :, Note : Delete clauses no ble,ANNEXUREV FOOD CORPORATION OF INDIA [MEDICAL REPORT FORM FOR EXAMINATION OF CANDIDATES. Candidate’ statement and Declaration PART-A The cangidate must make the statement required below prior to his Medical Examination and ‘must sign the Declaration appended thereto, His attention is specally directed to the warning contained in the Note below: 4. State your name in fulfin block letters) State your age and birth place 3. (a) Have you ever had smallpox, Intermittent or any other fever, enlargement or suppuration of lands spiting of ood, asthms, heart disease, lung eisease, fling attacks, rheumatism, appendicitis OR (©) any other disease or accident requiring confinement to bed and mesial or surgical 4. When were you last vacinatea? 55. Have you or any of your near relations been afflicted with consumption, serofula, gout, asthma, Ms, epilepsy, or insanity? 6. Have you sufferec from any form of nervousness due to overwork or any other cause? 7._ Furnish the following particulars concerning you family Fathers age Father's age No. of brothers Tio, of brothers Iflvig and atdeath and living, thei ages dead, their ages and state of health cause of death and state of heath cause of death, Wothersaee Mothers age No. ofasters Tio. ofsisters dead, Iftving and atdeath and living, theie ages theicages and cause State of heal cause of death and state of heath ofdeath ail Re stove srawers are othe best of my belie bu anecore Candidate's signature Signed in my presence, Signature ofthe examining medical authority. NOTE: The candidate willbe held responsible forthe accuracy of the above statement. By wilfully suppressing any information he wll incur the risk of losing the appointment, and if appointed, offorfeiting all aims to any reticerent and terminal benefits REPORT OF THE EXAMINING MEDICAL AUTHORITY BY{Name of candidate), PaRT-8 Phusical Examination 1. General development GOOD air Poor. Nutrition: Thin Average. Obs Height{without shoes), Weight Best welaht When Any recent change in weight? Temperature Girth of chest: (a) (After fll inspration) (2) (attr tll expiration} 2 Skin: Any disease. 3. Eyes: 1) Any disease. 2) Night blindness. 3) Flelé of sion, 4) Defect in colour vision. 5} Visual Acuity. Reaiiyor waked with ‘Srenath of lasses Vision eve Glasses ph oy is Distant Vision RE Le. Neat Vision RE Le. 4, Ears: Inspection, fearing: Reght Ear Left Ear 5. Glanes, Thyroid Condition f oath 1. Respiratory System: Does physical examination reveal anything abnormal inthe respiratory organs? tye, exalt uly 8. Circulatory System: (a) Heart: Any organic losers? ate Standing ‘After keeping 25 times, 2 minutes ater hopping. (b) Blood Pressure: Systolie Diastolic9. Abdomen: Girth Tenderness, sooo (a)Pelpalo: Lver. Saloon. Kidneys “Tumours (b) Haerorthaids. Fistula 10, Nervous system: Indications of nervous or mental disabilities, 11. Lacs-Mator System : Any; abnormality. 12. Genitor Urinary system : Any evidence of Lysrocolo,varcocole etc Urine Analysis: 2). Physial appearance. 4) Sp. Gr. {e) Albumin Suga. (e) casts A coli 13. Report of scresning/ X-Ray Examination 14. Isthere anythingin the health ofthe candidate likely to render him unfit forthe effietent discharge af his duties in tye service for whey he isa cancidate? 15. In case the cancidate is examined for more than one service/pos state for which services has he been examined and found inal respects qualified for the efficent and continuous discharge of his duties and for which of them he Is considered unit NOTE: The examining Medical Autrority should record ther fincings under one of the following three categories DF i) Unnit ii) Temporarily Unfit on aeceunt of Place Signature ofthe Examining Meciesl Authority *(Note:-This refers to temporary allments which canbe completely cured within a period of ‘Siemonths).‘Annexure - V (Under Section 38 of the Food Corporation Act, 1964) L declare that I will faithfully, truly and to the best ‘of my judgement, skill and ability execute and perform the duties which are required of me as director, member of the committee, officer employee or auditor {as the case may be) of the Food Corporation of India or as member of the Board of, Management of Food Corporation of India at New Delhi, under the Food Corporation of India and which properly relate to the office or position in or in relation to that Corporation held by me, I further declare that I will not communicate or allow to be communicated to any person not legally entitled thereto an information relating to the affairs of any person having any dealing with the said Corporation nor will Tallow any person not legally entitled as aforesaid to inspect or have access any books or documents belonging to, or in the possession of, the said Corporation and relating to the business of the said Corporation or the business of any person having any dealing with the said Corporation. (Signature) (Signed before me)‘ae ou 30 9509] Uo UY Aap 0 ay cxauaunuiodce 14 uo suoaeinsay (yes) Aap 1 240 Bp UORe\NBoy J9pun LoNeJotL0} 24 Jo Balo|diwa ALono Aq Pan Wgns pue Pays 2q 6 pouNba so} UOREsE==p OUI? ON ‘pavenpur aq Aew suorypuoewuesaid 0: ojeas ul anjenarewrosde ays Aaeana2e anjen aia s¥8558 03298500 I0u 13) asaum a2 ‘ose 2560] wior Hous popnpuld no Yonns 99 08 IENeD d}ae>IAe UN Ayodord oun spewey | woy osu envy Saar wa uossad yo speiap aie ue pue uopysinboe yoarep asiauno 208 souas2ys) ‘8eBuow ‘sea ‘358yp1nd Aa soureoun pavinbae mou sy20hoydu3 ude aig ovatysuonepas 04/51 pu p24 eu asaym ul ois ‘ue ume U:0U} ‘anyen pue 2upiNg quasaig 9490 ue Bujsnoy, «Avado1g sosjerep pur awen, pavenis si Aadoud pty ut 98248 ue nie ‘una ans sp Jo 2weN waimauuy {WBA 3HL 4Od /NAWINIOaY 1SULJ NO ALN3dOWd TIEVAOWINL 0 INSWISLVIS ug 0360 ed yuosaig pray sod yssaug (22uojaq 945/24 yum 04291195 pu ry ui 429450343 Jo WEN‘Annexure - VIT FOOD CORPORATION OF INDIA Cardex form (To be filled in by all employees at the time of joining service) 1. Name of the & ployee 2. Father's Name 3. Designation of the post to which appointed 4, Marital status (Married/single) 5. Wheather member of Scheduled (2) Caste (b) Tribe (Specify the particular caste/ tribe) 6. Identification Mark 7. (a) Permanent Address (b) Present address 8. Home-Town (for the purpose of LTC) 9. (a) Date of Birth (b) Particulars of birth i) Place ii) District ii) state 10. Languages the employee can (2) Read (2) Speak (©) Write 11, Mother Tongue 12. Educational Qualifications = 13.Technical Qualifications 14, Particulars of previous experience (service) (2) From (b) To (©) Posts(s) held (2 brief description of nature of work/ responsibilities in each assignment) (4) Officiating/ Substantive Capacity. ()_ Name of Employer (f) Scale of pay of the Post(s)15, Whether a Food Transferee/ Direct Recruit Absorbed Deputationist 16, If transferee ()) Date of joining the Food Deptt, & Designation held there (i) Gazette Notification No. ‘& Date under which services Finally transferred to FCI 17. Particulars of wholly dependant member of family (for the purpose of claiming LTC and reimbursement of medical expenses etc.) SI, No [Name of family member [ Relationsh Age Declaration Thereby declare that the above particulars furnished by me ere true to the best of my knowledge. I also undertake that any change in the above particulars shall be intimated by me at the appropriate time. I also Understand that any incorrect information submitted by me In this respect shall make me liable for service disciplinary action which may include a major penalty Signature Name Date Designation Station Office of Joining Certificate (To be recorded in case of existing employees only) ‘This is to certify that I have verified the above particulars submitted by the employee with the available documents and personnel file of the employee and found these in order and accepted the same. Office Stamp Signature Name and Designation,