ATTESTATION FORM
"Warning"
1. The furnishing of false information or suppression of any factual information in the Attestation Form would be disqualification, and is likely to render the candidate unfit for employment under the Government
Affix signed passport size (5 cm x 7 cm . Approx.)
2. If detained, convicted, debarred, acquitted etc. subsequent to the completion and submission of this form , the details thereof should be communicated immediately to the Goa public service Commission or the authority to whom the attestation form has been sent earlier, as the case may be, failing which it will be deemed to be a suppression of factual information.
3. 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.
1. name in full (in block capitals) with aliases, if any. (Please indicate if you have added or dropped in any stage any part of your name or surname
SURname name
2. Present address in full (i.e. village, Thana & District, or house Number, Lane/Street/Ward and Town)
3. (a ) Home address in full, if different from (2) above (i.e. Village, Thana & District, or House No.,
Lane/Street/Ward and Town & name of District Head Quarters)
(b) If originally a resident of Pakistan/Bangladesh (erstwhile East Pakistan) the address in that country and the date of migration to India Union
4. Particulars of places (with period of residence) 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 such places where you have resided for m ore than one year after attaining the age of 21 years, should be given.
Form To Residential address name of the
in full (i.e. Village, District Head
Thana and District or quarters of the place
House No. Lane/Street/ mentioned in the
W ard and Town). preceding column.
5. name Nationality
(by birth
and/or by
domicile)
Place
of
birth
Occupation
If employed
give designation
&
official
Address
Present
postal
Address
(If dead
give last
address)
Perm anent
Home
Address
i) Father's
(name full
aliases),
if any
ii) M other's
iii) Wife/husbands
iv) Brother (s)
v) Sister (s)
5 (a) information to be furnished with regard to son(s) and/or daughter(s) in case they are studying/living in a foreign country:
name Nationality
(by birth
and/or by
domicile)
Place of
birth
Country in which
studying/living
with full address
Date from
which
studying/living
in the country
mentioned in
previous
column
5. Nationality:
7. (a) Date of birth
(a)
(b) Present Age
(b)
(c) Age at Matriculation
(c )
8. (a) Place of birth, District and State in which situated
(a)
(b) District and State to which you belong
(b)
(c ) District and State to which your father originally belong
(c )
9. (a) Your religion
(b) Are you a Member of a Scheduled Caste/Schedules Tribe?
Answer 'Yes' or 'No'
1. Educational Qualification showing places of education with years in Schools and Colleges since 15th Year of age.
name of School/College
with full address
Date of
entering
Date of
leaving
Examination passed
11. (A) Are you holding or have any time held an appointment under the Central or State Government or 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, name of the employer, etc. up-to-date.
Period Designation,
emoluments and
nature of
employment
Full name and
address of employer
Reasons for leaving
previous service
From To
11. (B) If the previous employment was under the Government of India/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 month's notice under Rule 5 of the Central Service (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 of termination of a service, or at a subsequent date before your services actually terminated.
(Please strike off 'Yes' or 'No' as may be applicable and also write again in the blank space provided.
12 (i) (a) Have you ever been arrested ?
Yes/No
a) Have you ever been prosecuted?
Yes/No
(b) Have you ever been kept under detention?
Yes/No
(c) Have you ever been bound down ?
Yes/No
(e) Have you ever been fined by a Court of Law?
Yes/No
(d) Have you ever been convicted by a Court of Law for any offence?
Yes/No
(g) Have you ever been debarred from an Examination or rusticated by an University or any other educational authority/Institution?
Yes/No
(h) Have you ever been debarred/disqualified by any public service Commission from appearing at its Examination/Selection ?
Yes/No
(i) Is any case pending against you in any court of Law at the time of filling up this Attestation Form ?
Yes/No
(j) Is any case pending against you in any University
or any other educational authority/Institution at the time of filling up this attestation form?
Yes/No
(k) Whether discharge/expelled/withdrawn from any training institution under the Government or otherwise
Yes/No
(ii) 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 number of the case pending in the Country/University/Education authority etc., any time of filling up this form .
NOTE: (i) Please also see the 'Warning' at the top of this Attestation Form
(ii) Specific answers to each of the questions should be given by striking out 'Ye' or 'No' as the case may be.
_______________________________________________________________________
_
13. name and address of two responsible (i)
persons of your locality who are
in a position to vouch for your
Character and conduct. (ii)
Signature of Candidate
Verification
I, … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ..
(name in full) solemnly affirm and state 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 the Government.
Signature of the candidate
Date:-
Place:-
IDENTITY CERTIFICATE
(Certificate to be signed by any of the following)
(i) Gazetted Officials of Central or State Government.
(ii) Members of Parliament or State Legislature belonging to constituency where the candidate of his parent/guardian is ordinarily resident;
(iii) Sub-Divisional Magistrates/Officials.
(iv) Tehsildars or Naib/Deputy Tehsildars authorized to exercise magisterial powers.
(v) Principal/Head-Master of the recognized School/College/ Institution where the candidate studied last.
(vi) Block Development Officer.
(vii) Panchayat Inspectors.
Certified that I have known Shri/smt./Kum . … … … … … … … … … … … … … .. … … … … … … … … … … … … … … … … … … … … … … … … … … … … 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.
Place:- Signature____________________________
Date:- Designation or status and
Address:_____________________________
TO BE FILLED BY THE OFFICE
(i) name, designation and full address of the appointing authority.
(ii) Post for which the candidate is being considered