PN 99/2023 IN FORCE 2023-12-08

ANNEXURE-A-B AND Attestation form character tity and marital status

Document text

Sl roll cname gender dob cat1 cat2 cat3 mobile email_id alloc_post Post Name alloc_cat Rank Exam Center Date of Medical Examination Date of Physical Test Date of Document Verification Hospital 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1 7204020712 KULDEEP SINGH 2 12/2/1998 9

4 9639677885 kuldeepjadoun37.kj@gmail.com B18 Examiner 4 SL\II\07357 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 2 7204023272 UDARI RAGHUNANDAN VENKATAIAH 2 8/23/1997 1

8108655019 raghu23897@gmail.com B18 Examiner 1 SL\II\06155 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 3 7204022730 ASHUTOSH SINGH 2 11/15/1998 1

8233471825 ashutosh00796@gmail.com B18 Examiner 1 SL\II\05874 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 4 7208009060 RAHUL YADAV 2 8/9/1996 6

9654963896 rhlyadav5@gmail.com B18 Examiner 6 SL\II\02210 Pune 14.12.2023 16.12.2023 15.12.2023 St. George Hospital, Mumbai 5 7205017101 AKSHAY GUPTA 2 6/2/1996 9

8171472810 akshaygupta0081@gmail.com B18 Examiner 9 SL\II\01214 Nagpur 14.12.2023 16.12.2023 15.12.2023 6 7204018852 NAGENDRA SHARMA 2 5/8/1994 9

7014673992 sharmanagendra0805@gmail.com B18 Examiner 9 SL\II\01011 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 7 7204024860 LOVENESH KUMAR 2 3/10/1994 0

9899369534 loveneshnirwan@gmail.com B18 Examiner 9 SL\II\00531 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 8 7204021218 IYER ANANYA VENKATRAMANI 1 4/12/2000 9

5 8591119194 iyrananya@gmail.com B17 PO 5 SL\II\07593 Mumbai 14.12.2023 16.12.2023 15.12.2023 9 7208016062 DESHRAJ MEENA 2 7/6/1998 2

7891997085 deshrajkholwal@gmail.com B17 PO 2 SL\II\06524 Pune 14.12.2023 16.12.2023 15.12.2023 10 7207002379 PANDIT POOJA BALKRISHNA 1 5/21/1995 1

8329473664 poojapandit2105@gmail.com B17 PO 1 SL\II\06416 Nashik 14.12.2023 16.12.2023 15.12.2023 11 7207001787 CHETAN KUMAR SINGH 2 4/14/1997 1

6392865065 cks.bond@rediffmail.com B17 PO 1 SL\II\06406 Nashik 14.12.2023 16.12.2023 15.12.2023 12 7204002819 SUNIL KUMAR 2 8/30/1993 1

9812061553 sunigautam786@gmail.com B17 PO 1 SL\II\06366 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 13 7204014113 KUNAL JAGDISH SOMAIYA 2 10/1/1991 1

8369168316 somaiya91@gmail.com B17 PO 1 SL\II\06326 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 14 7205003885 HIMANSHU BHOJRAJ SHENDE 2 1/4/1999 1

8605837221 shendeh17@gmail.com B17 PO 1 SL\II\06248 Nagpur 14.12.2023 16.12.2023 15.12.2023 15 7204012791 ARUN VERMA 2 7/22/1994 1

8233320263 arunverma1011@gmail.com B17 PO 1 SL\II\06213 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 16 7204010111 VAIBHAV SARKAR 2 8/13/1993 1

9582603190 vbhvsrkr@gmail.com B17 PO 1 SL\II\05999 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 17 7208015539 RITESH KUMAR 2 8/20/1992 6

9199511501 riteshrk.aec@gmail.com B17 PO 6 SL\II\04009 Pune 14.12.2023 16.12.2023 15.12.2023 18 7208018618 ABHINAV SINHA 2 12/10/1998 6

8340591610 abhi1998sinha@gmail.com B17 PO 6 SL\II\03436 Pune 14.12.2023 16.12.2023 15.12.2023 19 7204015814 SURAJ KUMAR 2 6/10/1996 6

9650289901 surajsinghania1010@gmail.com B17 PO 6 SL\II\03427 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 20 7204021726 ASHISH PAL 2 5/15/1991 6

9557986333 pal.ashish5@gmail.com B17 PO 6 SL\II\03273 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 21 7207006380 ALOK RANJAN BISWAL 2 7/17/1993 6

9178014444 alok.rock003@gmail.com B17 PO 6 SL\II\03072 Nashik 14.12.2023 16.12.2023 15.12.2023 22 7207007036 SANJAY CHAUDHARY 2 4/16/1994 9

9810775773 sanjaycy007@gmail.com B17 PO 9 SL\II\02614 Nashik 14.12.2023 16.12.2023 15.12.2023 23 7204011395 VIVEK MALIK 2 7/10/1996 9

9634915550 vivekmalik020@live.com B17 PO 9 SL\II\02562 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 24 7204004402 NIRAJ KUMAR 2 2/12/1994 6

7903658195 kniraj597@gmail.com B17 PO 6 SL\II\02229 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 25 7204001777 SHANU ANAND 2 10/10/1995 6

6204692465 abcshanua@gmail.com B17 PO 9 SL\II\01985 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 26 7204001901 SANDARBH SINGH 2 1/3/1997 9

8827037512 sandarbhsingh27@gmail.com B17 PO 9 SL\II\01105 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 27 7204000432 RAJPUT VISHAL RAVINDRA 2 6/14/1996 0

9325299706 vishaalraajput@gmail.com B17 PO 9 SL\II\00773 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 28 7204010291 RAVIRANJAN KUMAR MISHRA 2 2/18/1995 9

5 6203898564 rrmishra95@gmail.com B16 Inspector 5 SL\II\07598 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 29 7208005222 POONAM 1 5/10/1990 9

5 9050874067 poonamsiwach10@gmail.com B16 Inspector 5 SL\II\07541 Pune 14.12.2023 16.12.2023 15.12.2023 30 7205012660 SOUMYA RANJAN MALLIK 2 7/2/1998 2

9777141435 malliksoumyaranjan007@gmail.com B16 Inspector 2 SL\II\07068 Nagpur 14.12.2023 16.12.2023 15.12.2023 31 7204014923 BHUKYA PRASAD 2 6/12/1996 2

6302847365 prasad.bhukya.789@gmail.com B16 Inspector 2 SL\II\06881 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 32 7208008873 HANSRAJ MEENA 2 7/7/1997 2

7877257572 hansrajmeena1234@gmail.com B16 Inspector 2 SL\II\06745 Pune 14.12.2023 16.12.2023 15.12.2023 33 7205006575 JAMGADE RAJAT SURESH 2 10/13/1996 1

9890796648 jamgader@gmail.com B16 Inspector 1 SL\II\06676 Nagpur 14.12.2023 16.12.2023 15.12.2023 34 7205017203 KATHANE AVINASH PRADIP 2 7/2/1997 1

8080747349 avinashkathane27@gmail.com B16 Inspector 1 SL\II\06667 Nagpur 14.12.2023 16.12.2023 15.12.2023 35 7205011497 SIDDHANT PRADEEP BAGDE 2 5/8/1998 1

8793116865 siddhantpbagde08@gmail.com B16 Inspector 1 SL\II\06657 Nagpur 14.12.2023 16.12.2023 15.12.2023 36 7204022952 SAURABH KUMAR MEENA 2 12/20/1991 2

9660447643 saurabh201991@gmail.com B16 Inspector 2 SL\II\06625 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 37 7207003847 AKASH KUMAR 2 4/18/1994 1

8233691246 akashk854@gmail.com B16 Inspector 1 SL\II\06623 Nashik 14.12.2023 16.12.2023 15.12.2023 38 7207004779 MANOJ KUMAR KOLI 2 1/26/1997 1

9358331993 koli.1997manojkumar@gmail.com B16 Inspector 1 SL\II\06621 Nashik 14.12.2023 16.12.2023 15.12.2023 39 7205022956 THOOL SAJESH SUDHIR 2 5/19/2000 1

9145354924 sajeshthool19@gmail.com B16 Inspector 1 SL\II\06605 Nagpur 14.12.2023 16.12.2023 15.12.2023 40 7208023123 DIGEMBER SINGH 2 7/18/1992 1

8875892291 digember18792@gmail.com B16 Inspector 1 SL\II\06555 Pune 14.12.2023 16.12.2023 15.12.2023 41 7204017589 NITIN KUMAR 2 11/18/1991 1

9456281826 nitkr1811@gmail.com B16 Inspector 1 SL\II\06546 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 42 7208015415 RIYA DANIYAL THORAT 1 6/5/2000 1

9579673286 thoratriya26@gmail.com B16 Inspector 1 SL\II\06519 Pune 14.12.2023 16.12.2023 15.12.2023 43 7214002727 MORE ATUL NANA 2 11/30/1999 1

7887301199 2017atulmore@gmail.com B16 Inspector 1 SL\II\06514 Jalgaon 14.12.2023 16.12.2023 15.12.2023 44 7201007033 GHATE YOGESH VASANT 2 6/20/1997 1

8484890471 ghateyogesh824@gmail.com B16 Inspector 1 SL\II\06485 Amravati 14.12.2023 16.12.2023 15.12.2023 45 7208005422 VIKASH KUMAR 2 12/31/1994 1

9110176378 vk5594969@gmail.com B16 Inspector 1 SL\II\06479 Pune 14.12.2023 16.12.2023 15.12.2023 ANNEXURE-A

46 7208002936 RAHUL KUMAR 2 1/25/1996 1

8789460258 rahulkumar3926@gmail.com B16 Inspector 1 SL\II\06428 Pune 14.12.2023 16.12.2023 15.12.2023 47 7205000570 SOMKUWAR VIPIN SURESH 2 12/30/1998 1

8408898658 vipinsomkuwar39@gmail.com B16 Inspector 1 SL\II\06414 Nagpur 14.12.2023 16.12.2023 15.12.2023 48 7205016887 JAMBHULKAR ANSHUL ARUN 2 12/15/1999 1

9403772591 anshul441206@gmail.com B16 Inspector 1 SL\II\06319 Nagpur 14.12.2023 16.12.2023 15.12.2023 49 7202008302 MAHENDRA GAIKWAD 2 5/8/1991 1

9356675145 mahendra.gaikwad7@gmail.com B16 Inspector 1 SL\II\06313 Aurangabad 14.12.2023 16.12.2023 15.12.2023 50 7205009998 BAGDE GAURAV VIJAY 2 3/4/2000 1

7249471962 bagdegaurav5@gmail.com B16 Inspector 1 SL\II\06305 Nagpur 14.12.2023 16.12.2023 15.12.2023 51 7205023955 DHEERAJ TONGARIYA 2 11/22/2001 1

9636197665 tongariyadheeraj@gmail.com B16 Inspector 1 SL\II\06303 Nagpur 14.12.2023 16.12.2023 15.12.2023 52 7205023811 BORKAR JAYESH MANOHAR 2 1/4/1998 1

9137139229 jayeshborkar2@gmail.com B16 Inspector 1 SL\II\06266 Nagpur 14.12.2023 16.12.2023 15.12.2023 53 7206000213 WAGHMARE SWAPNIL SAHEBRAO 2 8/12/1997 1

8329931248 swapnilwaghmare1997@gmail.com B16 Inspector 1 SL\II\06257 Nanded 14.12.2023 16.12.2023 15.12.2023 54 7204012700 PANKAJ KUNDAL 2 2/9/1997 1

9326077546 pankaj.kundal.180@gmail.com B16 Inspector 1 SL\II\06230 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 55 7206005526 NAWGHADE ROHIT CHANDRAKANT 2 6/2/2000 1

9764391133 sohannawghade123@gmail.com B16 Inspector 1 SL\II\06176 Nanded 14.12.2023 16.12.2023 15.12.2023 56 7205008089 GAURAV MEENA 2 3/4/1995 2

8085524406 grvmeena87@gmail.com B16 Inspector 2 SL\II\06163 Nagpur 14.12.2023 16.12.2023 15.12.2023 57 7204008422 VINOD KUMAR MEENA 2 2/25/1998 2

8955481268 vinodmandiya98@gmail.com B16 Inspector 2 SL\II\06089 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 58 7205010038 KANAK PATIL 2 2/16/1996 1

7972484114 kanak3033@gmail.com B16 Inspector 1 SL\II\06033 Nagpur 14.12.2023 16.12.2023 15.12.2023 59 7208018260 KAMBLE PURUSHOTTAM JITENDRA 2 12/27/2002 1

8010812048 27kamble@gmail.com B16 Inspector 1 SL\II\06020 Pune 14.12.2023 16.12.2023 15.12.2023 60 7201002100 RITIK PRABHAKAR DATAR 2 4/12/2001 1

9665722523 hritikdatar018@gmail.com B16 Inspector 1 SL\II\05932 Amravati 14.12.2023 16.12.2023 15.12.2023 61 7203001490 CHANDURE SANDIP PRADHANI 2 6/8/1993 9

7 9096728212 chanduresandip@gmail.com B16 Inspector 7 SL\II\05780 Kolhapur 14.12.2023 16.12.2023 15.12.2023 62 7204017630 JADHAV YOGESH VIJAY 2 10/17/1996 1

9757436443 001yog@gmail.com B16 Inspector 1 SL\II\05129 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 63 7208012932 MANISH MEENA 2 3/1/1992 2

9785656353 manish.pu39@gmail.com B16 Inspector 2 SL\II\04917 Pune 14.12.2023 16.12.2023 15.12.2023 64 7205023256 PATIL SUMIT SHANKARRAO 2 6/24/1993 9

4 8007599218 sumitsrp@gmail.com B16 Inspector 4 SL\II\04644 Nagpur 14.12.2023 16.12.2023 15.12.2023 65 7204018478 RAMAWATAR MEENA 2 9/15/1995 2

9414217714 rammina95@gmail.com B16 Inspector 2 SL\II\04272 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 66 7208020775 CHINMAY CHANDAN SAHOO 2 5/5/1992 6

9658445185 chinmaychandans31@gmail.com B16 Inspector 6 SL\II\03881 Pune 14.12.2023 16.12.2023 15.12.2023 67 7207007104 SATISH KUMAR 2 10/8/1998 6

7235940272 satishkumar74644@gmail.com B16 Inspector 6 SL\II\03868 Nashik 14.12.2023 16.12.2023 15.12.2023 68 7204003005 RAHUL MOHAN JADHAV 2 5/29/1991 6

8689855916 rahulash.987@gmail.com B16 Inspector 6 SL\II\03811 Mumbai 13.12.2023 16.12.2023 14.12.2023 GT Hospital, Mumbai 69 7204002290 RAHUL SINGH 2 1/8/1991 6

8826535996 rahul2rahul36@gmail.com B16 Inspector 6 SL\II\03746 Mumbai 14.12.2023 16.12.2023 15.12.2023 70 7204026137 JITENDRA SINGH YADAV 2 9/10/1992 6

9958909481 jitendrayadav.yadav987@gmail.com B16 Inspector 6 SL\II\03712 Mumbai 14.12.2023 16.12.2023 15.12.2023 71 7204006196 GOPAL GODARA 2 4/6/1995 6

8269261003 gopalgodara7@gmail.com B16 Inspector 6 SL\II\03701 Mumbai 14.12.2023 16.12.2023 15.12.2023 72 7205016395 RAHUL SAINI 2 3/15/1998 6

9785001611 rahulsaini15398@gmail.com B16 Inspector 6 SL\II\03644 Nagpur 14.12.2023 16.12.2023 15.12.2023 73 7204004379 UPENDRA 2 8/9/1996 6

7800770208 upendrakalan@gmail.com B16 Inspector 6 SL\II\03590 Mumbai 14.12.2023 16.12.2023 15.12.2023 74 7204015747 MOMIN MOHAMMED NOAMAN ASLAM 2 2/16/1995 6

8879212918 momin.noaman@gmail.com B16 Inspector 6 SL\II\03546 Mumbai 14.12.2023 16.12.2023 15.12.2023 Address of the Hospitals: 1 2 Gokuldas Tejpal Hospital, Near Police Commissioners Office, Lokmanya Tilak Marg, Fort, G. P. O, Mumbai, Maharashtra 400001 St George Hospital, Dadabhai Naoroji Road, Gpo, Mumbai, Maharashtra 400001

Medical Certificate of Fitness of Fist Entry into Government Service

I hereby certified that I have examined Shri/Smt………………………………………………………………………………………………………………………………… for the post of Inspector (CBIC) for the employment in the Customs Department/ GST Department and cannot discover that, he/she has any disease, constitutional weakness or bodily infirmity except …………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………

I do not consider this as a disqualification for employment in as Inspector (Examiner/Preventive Officer/GST) in Central Board of Indirect Taxes & Customs. His/Her age is according to own statement…………………………………………………………………years and by appearance about …………………………………… years. He/She has been vaccinated.  Height……………………cms.  Chest before expansion…………………cms for male candidate)  Chest after expansion…………………cms(for male candidate)  Weight…………………………kgs (for female candidate)

Mark of Identification: …………………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………

Seal & Signature of Civil Surgeon/Medical Officer

Place:

Name:

Date:

Reg. No.

A T T E S T A T I O N F O R M

WARNING: 1. The furnishing of false information or suppression of any factual information in the Attestation Form would be a disqualification & is likely to render the candidate unfit for employment under the Government. 2. If detained, convicted, debarred, etc., subsequent to the completion and submission of this form the details should be communicated to the Staff Selection 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 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.

(a) Name in full (IN BLOCK / SURNAME
NAME FATHER’S NAME CAPITAL LETTERS) with aliases if any:

(b) Please indicate if you have
added or dropped in at any
stage any part of your name
or surname.

Present address in full,
(i.e. Village, Thana & Dist.
or House No., Lane/Street/ Road & Town) & name of
Dist. Headquarters.

(a) Home address in full (i.e. Village, Thana & Dist., or House No. Lane/Street/Road & Town) & Name of Dist. Headquarters.

(b) If originally a resident of
Pakistan, the address in that
Country and the date of
Migration to Indian Union.

PLEASE AFFIX
YOUR RECENT
PASSPORT SIZE
PHOTOGRAPH

4 (a) Particular 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: -

Residential address Name of the Dist., Headquarters

in full (i.e. Village, of the place mentioned in the

Thana & Dist. Or
preceding column.

House No. Lane/ FROM TO

Street/Road & Town)

(b) Name Nationalit y (by birth & or by Domicile) Place of Birth Occupation (if employed give designation & official address) Present postal Address (If dead give last address) Permanent Home address. i. Father’s name

ii. Mother’s name

iii. Wife’s /
Husband’s name

iv. brother(s) name

v. Sister(s) name

Information to be furnished with regards to Son(s) and or Daughter(s) in case they are studying / living in a foreign country:

Name

Nationality

Country in which Date from which

(By birth &

studying / living studying / living in

By domicile)
with full address the country mentioned

In previous column

Nationality

:

(a) Date of Birth
: (b) Present age

: (c) Age at Matriculation :

(a) Place of Birth, Distt. & State :

in which situated

(b) Distt. & State to which you

Belong

(c) Distt. & State to which your :

Father originally belongs

(a) Your Religion

: (b) Are you a member of a Scheduled

Caste/Scheduled Tribes? Answer :

“Yes” or “No” & if the answer is

“Yes” state the name thereof. :

Education Qualification showing places of education, with years, in Schools & Colleges since the age of 15.

Name of School/

       Date of                    Date of                    Examination

College with full entering leaving passed Address.

(a) Are you holding or have at any time held an appointment under the Central or State Government or a Semi-Government or a private firm or institution? If so, give full particulars with dates of employment, up to date:

Period

Designation

Full name &

Reasons for leaving

Emoluments & address of the

previous service From To Nature of work Employer

Handled

(b) If the previous employment was under the Govt. of India / a State Govt./ An Undertaking owned or controlled by the Govt. of India or a State Govt./An Autonomous Body / University / Local Body. If you had left service on giving a month’s notice under Rule-5 of the 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 your conduct in any matter at the time you gave notice of termination of service, or at a subsequent date, before your services actually terminated: -

12(i)a. Have you ever been arrested? Yes / No

b. Have you ever been prosecuted? Yes / No

c. Have you ever been kept under detention? Yes / No

d. Have you ever been fined by a Court of Law? Yes / No

e. Have you ever been convicted by a Court of Law for any offence? Yes / No

f. Have you ever been bound down? Yes / No

g. Have you ever been debarred from any examination or rusticated by any

University or any other Educational Authority / Institution? Yes / No

h. Have you ever been debarred / disqualified by any Public Service

Commission for any of its Examination / Selection? Yes / No

i. Is any case pending against you in any Court of Law at the time of filling

up these Attestation Forms? Yes / No

j. Is any case pending against you in any University or any other Educational

Authority / Institution at the time of filling up these Attestation Forms? Yes / No

k. Whether discharged/ expelled/ withdrawn from any training/ institution

Under the Government or otherwise?

Yes / No (ii) If the answer to any of the above mentioned questions is “Yes”, give full particulars of the case / arrest / detention / fine / conviction / punishment, etc. and/ or the nature of the case pending in the Court/ University / Educational Authority, etc. at the time of filling up this Attestation 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 striking out “Yes” or “No” as the case may be.

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

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 Government.

Signature of Candidate
:_____________________________

Date

:_____________________________

Place

:_____________________________

Mobile No.

:_____________________________

6 -
I D E N T I T Y C E R T I F I C A T E

(Certificate to be signed by anyone of the following)

i. Gazetted officers of Central or State Government.

ii. Members of Parliament or State Legislature belonging to the Constituency where the Candidate or his parent / guardian is ordinarily resident.

iii. Sub-Divisional Magistrate / Officers.

iv. Tehsildars or Naib / Deputy Tehsildars authorized to exercise Magistrate powers.

v. Principal / Head Master of the recognized School / College / Institution where the candidate studied last.

vi. Block Development Officer.

vii. Post Master.

viii. Panchayat Inspector.

Certified that, I have known Shri / Smt. / Kum. _________________________________

Son / Daughter / Wife 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 of the candidate: ___________________

Date : _________________

Signature,
Designation or Status
& Address :___________________

TO BE FILLED BY THE OFFICE

i. Name, Designation & full address:
of the Appointing Authority

ii. Post for which the candidate is: Inspector (Examiner/Preventive Officer/GST) being considered

I hereby declare that, I am a Citizen of India. I was not a member of any unlawful organization. I am not a member of any unlawful organization and I shall not take part in activities of any unlawful organization. I have not been convicted by the Court of Law for any offence. I shall not be a member of, or be otherwise associated with, any political party or any organization which take part in politics nor shall I take part in, subscribe in aid of, or assist in any other manner, any political movement or activity.

I further declare that I am not a member of Provincial Unit of Territorial Army.

I am unmarried / married. *

I take the appointment as ________________________________ on service conditions laid down in the Appointment Memo

dated ______________________.

I will produce the Domicile Certificate within a month of this date.

I accept the seniority in the cadre of Inspector (Examiner/Preventive Officer/GST) in order of ranking assigned to me by the Selection Commission.

PLACE: ______________

DATE : ______________

        SIGNATURE OF THE CANDIDATE

Note*- Please strike out which is not applicable

D E C L A R A T I O N

I, Shri / Smt. / Kum. __________________________________________________
declare as under :-

i. That I am unmarried / a widower / a widow.

ii. That I am married and have only one wife living.

iii. That I am married and my husband has no other living wife to the best of my knowledge.

iv. That I am married and have more than one wife living. Application for grant of exemption is enclosed.

v. That I am married to a person who has already one wife or more living.
Application for grant of exemption is enclosed.

vi. I will not marry any woman / man having a living husband / wife without Government’s consent.

     2.**

I 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.

DATE : _____________

SIGNATURE___________________

NOTE :

Please delete the not applicable clauses.

** Applicable in the case of Clauses (i), (ii) & (iii) only.

VERIFICATION FORM FOR CANDIDATES UNDER CONSIDERATION FOR APPOINTMENT TO A SUBORDINATE SERVICE UNDER THE GOVT. OF INDIA.

I, ________________________________________________________ a candidate for the appointment to ______________________________________hereby certify that my answers to the following questions are correct. a. Have you previously been employed by the Central or any Provincial Government?

NO / YES

Department or Office in which previously employed. Designation of appointment.
Reasons for termination of appointment.

b. Have you previously applied without success for any appointment under the Central or a Provincial Government?

NO / YES

Department or office in which

Designation of appointment an appointment was sought.

applied for

I understand that if the above statement is false in any material respect my appointment is liable to be terminated.

PLACE : ______________

DATE : ______________

SIGNATURE

10 (A) - C H A R A C T E R C E R T I F I C A T E

Certified that I have known Shri / Smt. / Kum. __________________________________ ________________________________________ son / daughter of Shri / Smt. _____________ _________________________________ for the last ____________ years _________ months and that to the best of my knowledge and belief he / she bears a reputable character and has no antecedents which will render him / her unsuitable for Government employment.

Shri / Smt. / Kum. ________________________________________ is not related to me.

PLACE: ______________

GAZETTED OFFICER’S NAME & SIGNATURE

DATE : ______________

DESIGNATION: _________________________

OFFICE ADDRESS:

10 (B) - C H A R A C T E R C E R T I F I C A T E

Certified that I have known Shri / Smt. / Kum. __________________________________ ________________________________________ son / daughter of Shri / Smt._____________ _________________________________ for the last ____________ years _________ months and that to the best of my knowledge and belief he/she bears a reputable character and has no antecedents which will render him / her unsuitable for Government employment.

Shri / Smt. / Kum. ________________________________________ is not related to me.

PLACE : ______________

GAZETTED OFFICER’S NAME & SIGNATURE

DATE : ______________

DESIGNATION: _________________________

OFFICE ADDRESS:

11 - I D E N T I T Y C E R T I F I C A T E
[Certificate to be signed by any one of the following (*) Competent Authorities]

Certified that I have known Shri / Smt. / Kum. ________________________________________ son / daughter/wife of Shri _____________________________________________________ for the last

years

months, who is residing at

and it is also certified that the signatures and photograph attested below are of
Shri / Smt / Kum _______________________________________. His / Her identification marks are ___________________________________________________________________.

(Signature of Candidate) 





         Name, Designation, Signature and Address

of the Competent Authority

PLACE: ______________

DATE : ______________

(*) i) Gazetted officers of Central or State Government. ii) Member of Parliament or State Legislature belonging to the Constituency where the candidate or his parent/guardian is ordinarily resident. iii) Sub-Divisional Magistrate/Officers. iv) Tehsildars or Naib/Deputy Tehsildars authorized to exercise Magistrate powers. v) Principal/Head Master of the recognized School/College/Institution where the candidate studied last. vi) Block Development Officer. vii) Post Master. viii) Panchayat Inspector.

Recent Photograph duly attested by Competent Authority with seal (partly on photograph and partly on this certificate)

12 - INSTRUCTIONS TO BE FOLLOWED WHILE FILLING THE ATTESTATION FORM

Please read the instruction carefully and keep a blank copy extra before filling the Attestation forms. 2.
Please bring three sets of Attestation forms duly filled in ORIGINAL with complete address and Pin Code detail. 3.
Page 6 consists of Identity Certificate which has to be signed by Gazetted Officers of Central or State Government and the same officers should sign the first Character certificate on Page 10(A). 4.
Page 10(B) consists of 2nd Character Certificate which has to be signed by different Gazetted Officers of Central or State Government and the same officer should sign another Identity certificate on page 11. 5.
Please note both the Competent Authorities must be different as mentioned in the serial number 3 and 4 above. 6.
All the 3 attestation forms should be filled identically in candidate’s own handwriting and has to be signed in original. 7.
Failure to comply with the instructions would lead to undue delay in appointment. General Instructions Arrange the document in following order (Bring 03 sets -self attested with date) A. 10th Mark sheet and passing certificate B. 12th Mark sheet /Diploma Mark sheet and passing certificate C. Graduation mark sheets D. Degree Certificate (Graduation) E. Caste Certificate in required format (if applicable) F. Domicile Certificate G. Identity Card (Aadhar card/Pan card/Passport) H. Certificate of Physical Disability (if applicable) I. Service Leaving Certificate/Discharge book of Ex-Servicemen (if applicable to the candidate) J. Attestation Form (03 Sets in original)

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(b) Please indicate if you have added or dropped in at any stage any part of your name or surname.

Information to be furnished with regards to Son(s) and or Daughter(s) in case they are studying / living in a foreign country:

In previous column

:

: (c) Age at Matriculation :

Father originally belongs

“Yes” state the name thereof. :

Handled

OFFICE ADDRESS:

(b) Please indicate if you have
added or dropped in at any
stage any part of your name
or surname.