VERIFICATION ROLL

A passport size
recent
photograph is to
be pasted here
and it should
then be attested
by a gazetted
officer.
Surname Name
1. Name in full (in block letters) :
with aliases, if any, (Please
indicate if you have added or
dropped, at any stage, any part
of your name or surname)

2. The name of the post and the :

service applied for
3. Present address in full (i.e. :
Village, Post Office, Police
Station and District, or House
number, lane / Street /Road /
Area with PIN)
4. (a) Home(Permanent)address in full :
(i.e. Village, Post Office, Police
Station and District, or House
number, lane / Street /Road /
Area with PIN)

(b) Nationality :

(c) If originally a resident of

Pakistan / Bangladesh, the full
address in that Dominion and
the date of migration to Indian
Union

5.
Particulars of place where you have resided for more than one year during the preceding five
years--

From To Residential address in full (i.e. Village, Post Office, Police Station
and District, or House number, lane / Street /Road / Area with PIN)
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6. (a) Father’s name in full with (a)

aliases, if any.
(b) Present (postal) address (if (b)
dead, give last address)

(c) Permanent (home) address (c)

(d) Profession (d)

(e) If in service, give (e)

designation and official
address
7. (i) Nationality of --
(a) Father (a)

(b) Mother (b)

(c) Husband (c)

(d) Wife (d)

(ii) Place of Birth of--

(a) Husband (a)
(b) Wife (b)

8. (a) Exact date of birth (a) ____ _____ ________

[To be supported by Birth DD MM YYYY
Registration Certificate/Admit
Card of West Bengal Board of
secondary Education/any other
recognized Board]
(b) Present age (b)

(c) Age at Matriculation (c)

/School Final Examination

9. (a) Place of birth, District and (a)

state in which it is situated.

(b) District and State to which (b) District: …………………………..

you belong
State: ……………………………..
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10. (a) State your religion (a)

(b) Are you a member of a (b)

Scheduled Caste /
Scheduled Tribe / O.B.C. ?
(Answer yes or no if the
answer is yes, state the
name thereof. [copy of
certificate to be attested]

(c) Whether married or (c)

Unmarried

(d) Distinguished mark of (d)

identification

11. Educational qualification’s showing places of education with years in schools and colleges
(from Madhyamik or X-standerd onwards) –

Name of school/ college with full Date of Date of Examination Passed.

address. entering. leaving.

12. If you have at any time been employed, give details -

Period
Designation of post held or From To Full address of the office firm or Institution
description of work and reasons for leaving previous service.

13. Have you ever been arrested/detained/ :

convicted by a court of law / office ?
If the answer is ‘yes’ the full
particulars of the
arrest/detention/conviction and the
sentence thereof should be given.
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14. Names with addresses of 1.

two responsible persons of
your locality or two
referees to whom you are
known.

2.

I certify that the foregoing information are correct and complete to the best of my knowledge and
belief. I am not aware of any circumstances, which might impair my fairness for employment under
Government. I understand that submission of false information will make me ineligible for employment.

Date ………………………..
Place……………………….. Signature of Candidate……………………………………………..

(Certificate to be signed by a Gazetted Officer/Member of Legislative Assembly/Parliament or other authority

prescribed by the appointing authority)

Certified that I have known Shri/Shrimati/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.

Date ……………………… Signature of the Competent Authority

Place………………………..
NAME …………………………………………………………….

Designation ……………………………………………..

Address …………………………………………………

…………………………………………………..
Seal :

(Signature and designation of the issuing Officer)