Fillable Printable Attestation Form
Fillable Printable Attestation Form
Attestation Form
Police verification/attestation form
ATTESTATION FORM
WARNING:-
1. The furnishing of false information or suppression
Affix passport size
photograph here
of any factual information in the Attestation Form
would be a disqualification and is likely to render
the candidate unfit for employment under the Govt.
2. If detained, 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 to whom the
attestation form has been sent early, failing which
it will be deemed to be a suppression of factual information.
3. If the fact that false information has been furnished or there has been suppression of any factual
information in the attestation form comes to notice at a time during the service of a person, his/her
services would be liable to be terminated.
(i) Name in full (IN BLOCK CAPITALS) :
with alias, if any. (Please indicate if you have added or
dropped in any stage any part of your name or surname)
(ii) Present address in full :
(i.e. Village / Thana / District or House No./ Lane/
Street / Road / Town and name of District Hqrs.)
(iii) (a) Home address in full :
(i.e. Village / Thana /District or House No./Lane /
Street / Road / Town and name of District Hqrs.)
(b) If originally a resident of Pakistan, the address in
that country and the date of migration to Indian 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 places
where you have resided for more than one year after attaining the age of 21 years should be given.
S. No. From To Residential address in full (i.e.
Village / Thana / District or
Door No. / Lane / Street /
Road and Town)
Name of the Hqrs. of the
places mentioned in the
preceding column
Members
of family
Name (with
alias, if any)
Nationality Place of
Birth
Occupation (if
employed, give
designation and
Office address
Present postal
address and
permanent Home
address
1
2
3
4
5
Father
Mother
Wife /
Husband
Brother/s
Sister/s
5. Information to be furnished with regard to son(s) and daughter(s) in case they are studying / living
in a foreign country.
Name Nationality
(By birth or
Domicile)
Place of
birth
Country in which
studying/living with
full address
Date from which
studying in the
country mentioned
in previous column
6. Nationality (by birth or Domicile) :
7. (a) Date of birth :
(b) Present age :
(c) Age at Matriculation :
8. (a) Place of Birth/District & State in which situated :
(b) District & State to which you presently belong :
(c) Distt & State to which your father originally belonged :
9. (a) Your religion :
(b) Are you a member of SC / ST / OBC :
(strike out whichever not applicable)
(c) Name of the Caste :
(d) Category of candidature (PH / EX-SM / Dependents of EX-SM killed in action) :
(strike out whichever not applicable)
10. Educational qualification showing places of education with years in School(s) and Colleges(s) since
15
th
year of age.
Name of School/ College
with full address
Date of entrance Date of leaving Examination(s) passed
11. (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, up-to- date.
Period
From To
Designations,
Emoluments and
nature of
employment
Full name and address of
the employer
Reasons for leaving
previous service
(b) If the previous employment was under the Government of India / a State Government / an
Undertaking owned by or controlled by the Government of India or a State Government /an
autonomous body / University / local body.
(state whether you had left service on giving a month’s notice under Rule 5 of Central Civil Services
(Temporary Service ) Rules, 1965, or any similar corresponding rules where any disciplinary
proceedings framed against you, or had you been called upon to explain you conduct in any matter
at the time you have been served with notice of termination of service, or at a subsequent date,
before your services were actually terminated).
12. (a) Have you ever been arrested? : Yes / No
(b) Have you ever been prosecuted? : Yes / No
(c) Have you ever been kept under : Yes / No
detention?
(d) Have you ever been bound down? : Yes / No
(e) Have you ever been fined by a Court : Yes / No
of Law?
(f) Have you ever been convicted by a : Yes / No
Court of Law for any offence?
(g) Have you ever been debarred from any : Yes / No
examination or restricted by any
University or any other educational
Authority / Institution?
(h) Have you ever been debarred / : Yes / No
disqualified by any Public Service
Commission/Staff Selection Commission
for any of its examinations / selections?
(i) Is any case pending against you in any : Yes / No
University or any other Educational
Authority / Institution at the time of
filling up this Attestation Form?
(j) Is any case pending against you in : Yes / No
any Court of law at the time of filling
up this Attestation Form?
(k) Whether discharged/expelled/ : Yes / No
withdrawn from any training institution
under the Govt. or otherwise?
If the answer to any of the above mentioned questions is “Yes”, give full particulars of the case Viz.
arrest/ detention/ fine/ conviction/ sentence/ punishment, etc., and the nature of the case pending in
the Court/ University/ Educational authority, etc. at the time of filling up of this form.
NOTE : (i) Please also see the ‘WARNING’ at the top of this form.
(ii) Specific answers to each of the questions should be given
by striking out “Yes” or “No” as the case may be.
13. Name and addresses of two responsible persons of your locality or two references to whom you are
well known.
(1)
(2)
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 THE GOVERNMENT OF INDIA.
Date :
Place : Signature of the candidate/ employee
Annexure
IDENTITY CERTIFICATE
Certificate to be signed by any one of the following:
1. Gazetted Officer of Central or State Government.
2. Member of Parliament or State Legislature belonging to the constituency where the candidate or
his/her parent/ guardian is originally residing.
3. Sub-Divisional Magistrate/Officer/Block Development Officer
4. Tehsildar or Naib/Deputy Tehsildar authorized to exercise magisterial powers.
5. Principal of the both recognized school/institution where the candidate studied last.
6. Registrar/Dy Registrar/Assistant Registrar of University.
7. Post Masters
8. Panchayat Inspectors/ Mukhiya/ Pradhan/ Sarpanch etc
9. Principal/Vice-Principal of Colleges.
10. Office of the Indian Embassy/ Consulate General.
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.
Place................................ Signature
Date................................. Designation or status and address
(To be filled in by the office)
1. Post for which the candidate/employee is being considered……………………………………………..……….
2. Name /Designation of the appointing authority…………………………………………………………………………….
IN CASE YOU HAD BEEN ABROAD, PLEASE FURNISH THE FOLLOWING PARTICULARS IN
FULL ABOUT YOUR PASSPORT
(a) Passport number: ...............................................
(b) Date and Place of issue........................................
(c) Name:...............................................................
(d) Place and date of birth.........................................
(e) Father’s Name: ............................. ...................
(f) Home town: .............................. ..............................
(Note: Mention Item numbers c, d, e, and f as described in the passport)
Signature of candidate/ employee
Signature of Attesting Authority
Designation or status and address
Date ........................................
(To be furnished by candidate who has stayed/lived in foreign countries )
I..............................................................................S/o.......................................................
born on.................................. in Village .....…………………………………......Pin...................................
District.....................................................................State..................................... and having
stayed/lived in .....................................................................................................................
(name of the country) at (name of place(s) with full address........................................................
...........................................................................................................................................
............................................................................................................... hereby signify my
consent that I have no objection to any of my personal information being disclosed by the appropriate
authority in .......................................(name of country)
Date........................... Signature of candidate/employee
Full name
