Attestation form for uploading (Compassionate Ground appointment)

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.

1. (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.

3. (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

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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)

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(b) Name Nationality (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

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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

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Nationality :

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7. (a) Date of Birth : (b) Present age : (c) Age at Matriculation :

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8. (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

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9. (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. :

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

Name of School/

                       Date of Entering        Date of Leaving      Examination Passed 

College with full Address.

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11. (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

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11. (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: -

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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

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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.

1.______________________

2._______________________

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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 :

• 7 – TO BE FILLED BY THE OFFICE

i. Name, Designation & full address: Addl. Commissioner of Customs, of the Appointing Authority Personnel & Estt. Deptt., New Custom House, Ballard Estate, Mumbai-400001

ii. Post for which the candidate is: (TAX ASSISTANT) being considered PERSONNEL & ESTT. DEPTT., New Custom House, Ballard Estate, MUMBAI – 400 001.

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 in Mumbai Custom House, on service conditions laid down in the Mumbai Custom House, Appointment Memo

dated .

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

PLACE: _ DATE :

SIGNATURE OF THE CANDIDATE

• 8 – D E C L A R A T I O N

1. 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.

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

I, a candidate for the appointment to

answers to the following questions are correct. hereby certify that my 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:

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-: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:

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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)

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Name, Designation, Signature and Address of the Competent Authority

PLACE: _ DATE :

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

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

COMBINED GRADUATE LEVEL EXAMINATION, 2022

              DOCUMENT VERIFICATION PROFORMA FOR (Tax Assistant) 

SR.NO. PARTICULARS DETAILS(IN BLOCK LETTERS) 1 NAME OF THE CANDIDATE 2 ROLL NO. & RANK 3 FATHER’S NAME 4 MOTHER’S NAME 5 LANDLINE /MOBILE NO 6 EMAIL ADDRESS 7 DEGREE CERTIFICATE DETAILS

A CERTIFICATE NO. AND DATE B MARKSHEET SR.NO. AND DATE C ENROLLMENT NO. D ISSUING AUTHORITY DETAILS (ADDRESS WITH PINCODE) 8 SECONDARY SCHOOL CERTIFICATE DETAILS

A CERTICATE /MARKSHEET NO. AND DATE B ROLL NO. C ISSUING AUTHORITY DETAILS (ADDRESS WITH PINCODE) ` 9 DOMICILE CERTIFICATE DETAILS

A CERTIFICATE NO. AND DATE B ISSUING AUTHORITY DETAILS (ADDRESS WITH PINCODE ) 10 AADHAR NUMBER 11 CASTE CERTIFICATE DETAILS

A CERTIFICATE NO. AND DATE B ISSUING AUTHORITY DETAILS (ADDRESS WITH PINCODE) 12 CHARCTER AND ANTECEDENT VERIFICATION DETAILS

A DISTRICT MAGISTARTE (ADRESS WITH PINCODE) B SUPERINTENDENT OF POLICE (ADRESS WITH PINCODE)

I, HEREBY DECLARE THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Date- NAME AND SIGNATURE OF CANDIDATE

CANDIDATE’S STATEMENT AND DECLARATION The candidate must make the statement required below prior to this medical examination and must sign the declaration appended thereto. His attention is specifically directed to the warning contained in the Note below.

1 State your name in full (In Block Letters) 2 State your age & Place of Birth 3 a) Have you ever had Small pox, Intermittent or any other Fever, Enlargement or Suppuration of Glands, spitting of blood, Asthma, Heart Disease, Lung

Disease, Fainting attacks, Rheumatism, Appendicitis? (OR) b) Any other disease or accident requiring confinement to bed and

medical or surgical treatment? 4 When you were last vaccinated? 5 Have you or any of your near relations been afflicted with Consumption, Scrofula, Gout, Asthma, Fits, Epilepsy or Insanity? 6 Have you suffered from any form of nervousness due to overwork or any other cause? 7 Have you been examined and declared fit for Government service by a Medical Officer/ Medical Board, within the last three years?

Furnish the following particulars concerning your family:

Father’s age if living and state health Father’s age at death and cause of death No. of brothers living, their ages and state of health No. of brothers, dead, their ages at death and causes for death

Mother’s age if living and state health Mother’s age at death and cause of death No. of Sisters living, their ages and state of health No. of Sisters, dead, their ages at death and causes for death

I declare all the above answers to be, to the best of my belief, true and correct.

I also solemnly believe that I have not received a disability certificate / pension on account of any disease on other condition.

Signed in my presence

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Candidate’s Signature (Signature of Medical Officer)

Note: The candidate will be held responsible for the accuracy of the above statement. By wilfully suppressing any information he/she will incur the risk of losing the appointment, and, if appointed, or forfeiting all claims to superannuation allowance or gratuity.

Medical Certificate of Fitness of First Entry into Government Service (Male Candidates)

I hereby certified that. I have examined Shri

/Smt..for the post (TAX ASSISTANT) for the employment in the Customs Department and cannot discover that, he has any disease, constitutional weakness or bodily infirmity except_____________________________________________________ __________________________________________________________________________________________. I do not consider this a disqualification for employment in the office of the Principal Commissioner of Customs (G), P&E (Ministerial) New Customs House, Ballard Estate, Mumbai- 400 001. His age is according to his own statement___________years and by appearance about

__________Years. Height_________cms. & Weight___________Kgs.

He has been vaccinated.
(Yes/No)

Mark of Identification: _____________________________________________________________________

_________________________________________________________________________________________________________________________________________.

Left Hand Thumb Impression of Signature and Seal of Civil Candidate Surgeon/Medical Officer

Name :

Reg. No. : Signature of the Candidate

Place:

Date :

Note:- Photograph attested by surgeon/Medical Officer with seal (partly on photograph and partly on this certificate Recent Passport Size Photograph of the Candidate

Medical Certificate of Fitness of First Entry into Government Service (Female Candidates)

I hereby certified that. I have examined Ms/Smt._______________________________ for

the post of (TAX ASSISTANT) for the employment in the Customs Department and cannot discover that, she has any disease, constitutional weakness or bodily infirmityexcept__________________________________________________________________________

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I do not consider this a disqualification for employment in the office of the Principal Commissioner of Customs (G), P&E (Ministerial) New Customs House, Ballard Estate, Mumbai- 400 001. Her age is according to her own statement________years and by appearance about

___________.Years. She has been vaccinated, Height__________cms. & Weight ______Kgs.

Mark of Identification:- _____________________________________________________________

_________________________________________________________________________________________________.

Left Hand Thumb Impression of Signature and Seal of Civil Candidate Surgeon/Medical Officer

Name :

Reg. No. : Signature of the Candidate

Place:

Date :

Recent Passport Size Photograph of the Candidate

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.

Please bring four sets of Attestation forms duly filled in ORIGINAL with complete address and Pin Code detail 4. Character Certificate on Page 10(A) has to be signed by the one of the Competent Authorities mentioned on the the Identity Certificate on Page 6.
5. Character Certificate on Page 10(B) has to be signed by different Competent Authority and the same Authority should sign the Identity certificate on page 11. 6. Please note both the Competent Authorities must be different as mentioned in the serial number 4 and 5 above. 7. All the 4 attestation forms should be filled identically in candidate’s own handwriting and has to be signed in original. 8. Failure to comply with the instructions would lead to undue delay in appointment.

General Instructions

Arrange the document in following order (Bring 04 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 (04 Sets in original)