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Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

1

Shri M.S.V. Durga PrasadS/o M V Ramana EWS-176, APIIC Colony,Kamalanagar, ECIL, ECIL POST, KeesaraMandal, Rangareddy District, Hyderabad -500062

UR 21.05.1990

2

Shri Gadhiraju Kalyan VarmaS/o Prasada Raju,Flat No. 201, PanchavatiApartments, Opp. RTO, Khammam,Telangana - 507002

UR 21.12.1989

3

Shri R.Sricharan ReddyS/o R. Laxma Reddy,H.No. 9-4-43,Srinagar Colony, Karimnagar, Telangana -505001

UR 28.07.1994

4

Shri P.Sunanda Kumar S/o Vijaya Kumar,Flat No. 8D,V.V.ILLAM Palayathan 2ndStreet, Bharath Nagar, Camp Road,Selaiyur, Chennai - 600073

UR 05.07.1990

5

Shri Annaparthi Surendra KumarS/o Prem Kumar, H.No. 11-20-14/206,Ratnadeepika Apartments, Huda Complex,Saroornagar, Hyderabad, Telangana -500035

UR 15.06.1992

6

Shri V.Raghuveer Reddy S/o GovardhanReddy ,1-9-53/14, Ramnagar,Musheerabad, Hyderabad, Telangana -500020

UR 04.04.1989

7

Shri K Sharat Chandra ReddyS/o Mohan Reddy, 12/45 Ground Floor, OldRajindra nagar, Near Yashoda Dairy, Delhi -110060

UR 20.10.1989

8

Ms Kirti LambaD/o Rajesh Lamba, H.No.-233,VPO-Qutabgarh, North West Delhi, Delhi -110039

UR 01.09.1994

9

Shri Kshitij BansalS/o G.D Bansal, E-4/106,First Floor, Sector-7, Rohini, North WestDistrict, Delhi - 110085

UR 06.03.1989

10

Ms Ankita PandeyD/o Sunil Kumar Pandey,H.No 8/10/81/37, Ram Nagar Colony, InFront of Sindhi Gate, Faizabad, UttarPradesh - 224001

UR 10.09.1994

11

Shri Vipin KumarS/o Jasbir Singh, H-107,Pallavpuram Phase-I, Modipuram, Meerut,UttarPradesh - 250110

UR 08.06.1991

LIST OF THE CANDIDATES NOMINATED BY SSC FOR APPOINTMENT TO THEPOST OF TAX ASSISTANT THROUGH CGL-2015

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

12

Shri M Vinod KumarS/o M Damodar Rao, Plot No. 33,H.No.5-5-1203, Ganesh nagar Colony,Vanasthalipuram, Hyderabad - 500070

UR 12.06.1989

13

Shri Sudhanshu ThukralS/o Vinod Thukral WZ-68(C-4), Mukherjeepark, Tilak Nagar, New Delhi - 110018

UR 06.03.1991

14

Shri Arunesh Ram TripathiS/o Rajesh Tripathi 2/142, Vikas Nagar,Lucknow, Uttar Pradesh - 226022

UR 16.11.1990

15

Shri Sachin KumarS/o Jaidev Sharma, VPO Lank, ShamliDistrict, Uttar Pradesh - 247776

UR 07.01.1992

16

Ms Neetu GuptaD/o Prem Chand Gupta, # 21826-A, NearShiv Mandir, Power House Road, Bathinda,Punjab - 151001

UR 08.12.1988

17

Shri Manish SinghS/o Babulal Singh, Panchsheel, Primrose, F-1201, T-2, ADJ Police Reserve Line, hapurRoad, Ghaziabad, Uttarpradesh - 201002

UR 15.04.1989

18

Ms Megha MehndirattaD/o Sanjay Mehndiratta D-5/A, GroundFloor, Vijay Nagar, Single Storey, NorthWest Delhi, Delhi - 110009

UR 29.08.1992

19

Shri Ashish DixitS/o Arun Kumar Dixit, Behind Middle StateSchool, Power House Road, Ratangarh,Churu, rajasthan - 331022

UR 26.06.1991

20

Shri Prashant SinghS/o Birendra Pratap SinghFlat No. T-V/2, Sanchar Vihar Colony,Barrage Road, Bijnor, Uttarpradesh -246701

UR 13.09.1988

21

Ms. JulieD/o Yogender Singh, H.No-A/40, NewSanik Vihar, Fazalpur,Near S.B.I, Meerut,Uttar Pradesh - 250001

UR 20.07.1990

22

Shri Vinay GargS/o Raj Kumar Garg, Flat No.29, Pocket 1,Sector A9, DDA Flats, Narela, Delhi -110040

UR 08.06.1990

23

Ms. Hemlata GuptaD/o Suresh Chand Gupta,Bookna wale, Sapotra Mod, Sapotra, Tech-Sapotra, Karauli Dist,, Rajasthan - 322218

UR 10.06.1992

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

24

Shri Manoj KumarS/o Shish Pal Singh,H.No - DS 27, Type-4, Thermal Colony,Panipat, Haryana - 132105

UR 27.10.1988

25

Shri Manoj KumarS/o Balraj Singh,H.No.-117, Jailder wali Gali, V.P.O. BajitpurThakran, North West District, Delhi -110039

UR 28.01.1991

26

Shri Y Siva Sai KrishnaS/o Y Chenna Reddy, Plot No: 106, First Floor, PragathiNagar, Opp. JNTUC, Kukatpally,Hyderabad - 500090.

UR 21.08.1992

27

Shri Nirbhay SinghS/o Harendra Singh, VPO-sinsini, Thok-Paiju, Via-Kumher, Bharatpur, Rajasthan -321201

UR 15.08.1994

28

Ms. PinkiD/o Jaipal Singh, H.No. 342, Behind RajCinema, Subhash Nagar, Rohtak, Haryana-124001

UR 29.06.1990

29

Shri Amit Khokher S/o Hemchander,H.No.574/10, Ram Gopal Colony, BehindP.N.B, Near Petrol Pump, Rohtak, Haryana-124001

UR 27.08.1989

30

Shri Dainik JainS/o Rishabh Jain,67, Roop Nagar, Sector-3, Hiran Magri,Near Kesar Bagh, Udaipur Rajasthan-313002

UR 22.12.1991

31

Shri Jitendra Kumar KhatriS/o Hemant Kumar Khatri, 176/72 PratapNagar, Sanganer, Jaipur, Rajasthan-302033

UR 04.12.1989

32

Shri Sumit KumarS/o Satish Kumar,Vill.Tihara Kurd,P.O Tihar Baghru, Sonipat,Haryana-131001

UR 13.02.1992

33

Ms. Mohammed Hafsa D/o Md. AzeemMohiddin D.No.24-2-746, Flat No.102, ABlock, Rohitha Paradaise, Besides HotelLeo, Dargamitta, Nellore Dist., AndhraPradesh-524003

UR 13.02.1992

34

Ms. Aarti TyagiD/o Sunil Tyagi,H.No.3459-V, Sector-15, Part-3, Sonipat,Haryana-131001

UR 01.05.1992

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

35

Shri Rohit JainS/o Vijay Raj Jain, 231,Ward No.10, JainChowk,Nokha, Bikaner-334803

UR 10.11.1988

36

Shri VikasS/o Rajpal, H.No.-608, Ward-23, MohanNagar, Near Vijaya Sr. Sec. School,Bahadurgarh, Jhajjar, Haryana-124506

UR 02.11.1991

37

Shri Allanki SudheerS/o A.Venkateswarlu,D.No. 1-188, Bodduvaripalem,Santhanuthalapadu, Prakasham Dist.,AndraPradesh-523225

UR 04.04.1989

38

Smt. Archana SharmaD/o Ram Kumar, H.No.243/19, KailashColony ,Near I.T.I Gate,Sonipat, Haryana-131001

UR 04.02.1990

39

Shri Sanjay Singh DangiS/o Bahadur Singh Dangi, B.S.V. InterCollege, Kashipur Raod, Jaspur, UdhamSingh Nagar Uttarakhnad-244712

UR 06.01.1990

40

Shri Aditya sharmaS/o Suresh Kumar sharma, Flat No.-52/203, AMD Flats, Sector-5, Pratap NagarSanganer, Jaipur Rajasthan-302033

UR 01.09.1991

41

Shri Piyush SinghS/o Surender Singh, Q-57, Sector-1,R.K.Puram ,New Delhi-110022

UR 23/10/1992

42

Shri G.Narayana ReddyS/o G.Narasimha ReddyH.No. 2-79, Gotur Village, DhanwadaMandal, Mahabubnagar, Telangana -509204

UR 27.05.1992

43

Ms Nidhi KaushikD/o S C Kaushik, C/o KaushikElectricals, Near SRS Sector 3, Ballabgarh,Faridabad, Haryana - 121004

UR 04.06.1991

44

Shri Sunil Kumar TiwariS/o Ram Suresh Tiwari Village Badwara,Post Badwara, Katni District, MadhyaPradesh - 483773

UR 17.09.1989

45

Shri Virendra SinghS/o Padam Singh, Plot No. 115, RoadNo.29, RTO Office, ZSB BJS Colony,Jodhpur, Rajasthan - 342001

UR 02.02.1992

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

46

Ms Aayushi JainD/o Pawan Kumar Jain, IA-55AAshok Vihar PH-1, Opp. MontFort SchoolMIG Flats, North West Delhi, Delhi -110052

UR 13.03.1991

47

Shri Chilapuram RajeshS/o Chandraiah, H.No.15-113/1, Near Doodi malla ReddyFunction Hall, Hanuman Nagar, Siddipet,Medak, Telangana - 502103

OBC 25.08.1990

48

Shri Tummalacharla Leela PrasadS/o Sree Ramulu, #5126, MAC Colony,Behind BHEL Factory, RC Puram,Hyderabad, Telangana - 502032

OBC 12.07.1991

49

Shri Yathirajula Bhanu ChanderS/o Venkata Rao 8-15-43, Opp.Venkateswara Temple, balaji Nagar,Vizianagaram, Andhra Pradesh - 535003

OBC 02.08.1992

50

Shri P.Siva KrishnaS/o P. Venkata Subbaiah D.No: 3-32,Iskapalli Vill, Allur Mandal, SPSR NelloreDistrict, Andhra Pradesh - 524324

OBC 09.06.1992

51

Shri Sandolla DasharathS/o Naga Bhushanam H.No. 6-128, BagathSingh Chowk, Boath Village, Adilabad,Telangana - 504304

OBC 16.02.1992

52

Shri Jella NagarjunaS/o J Satyanarayana, H.No.7-4-12/12, Plot No. 12, Tirumala Colony,Behind Alpha High School, Chintal Kuntacheckpost, LB Nagar, Hyderabad,Telangana - 500074

OBC 28.01.1986

53

Shri Amit kumarS/o Natho Sharma C/o Bal Krishna Mistri,AT-Station Road barh, Near VishwakarmaMandir, P.O. PS Barh, Patna, Bihar -803213

OBC 08.01.1988

54

Shri Gaurav SharmaS/o Anil Kumar Sharma, Madhopur, NearDhobi Tola, Post Basudeopur, Munger Dist,Bihar - 811202

OBC 10.08.1989

55

Shri RahulS/o Radhe Shyam c/o Gaya Prajapati,Anupam Colony,Room No.E-21, Husainabad, PostKutchery, Jaunpur, Uttar Pradesh - 222002

OBC 23.07.1992

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

56

Shri Rahul KumarS/o Hari Singh, Village MandiaKhwajpur, Post: Khwajpur Dhantla, tehsil:Thakurdwara, Moradabad, Uttar Pradesh -244601

OBC 20.02.1996

57

Shri Sarwar AliS/o Akbar Ali, 40 North Goala Para,PO:Angus, PS: Bhadreswar Dist: Hooghly,West Bengal - 712221

OBC 23.05.1992

58

Ms Boddeda SravyaD/o Venkatanageswara RaoD.No. 46-5-70, Pulivari Street,Dondaparthy, Visakhapatnam - 530016

OBC 23.08.1991

59

Shri Pulluru Durga PrasadS/o P Prabhakar8-4-371/B/29, Plot No. 137, Flat No.301, saiKuteer Apartments, Kalyan Nagar-III, MotiNagar, Hyderabad - 500018

OBC 02.10.1986

60

Ms Sujata SharmaD/o Surat Singh, Gulabi Bagh,Gali No 1, Rewari, Haryana - 123401

OBC 23.11.1991

61

Shri RavikantS/o Satyanarayan, VPO Dhana Khurd,Tehsil Hansi, Hisar District, Haryana -125033

OBC 04.07.1990

62

Shri Avinash RanjanS/o Vijay Singh, Barki Kharari (V&M), PO-Barki Kharari, PS-Karagahar, Rohtas Dist.,Bihar - 821113

OBC 20.01.1993

63

Shri Sugna RamS/o Mana Ram, 341, Baba ki Dhani, Nimod,Teh: Deedwana, Nagaur, Rajasthan -341506

OBC 15.10.1993

64

Shri Sachin RawalS/o Suresh Rawal, Village:Behrampur, PO Bapoli, Teh: Bapoli,Panipat, Haryana - 132104

OBC 05.12.1991

65

Shri Gajender YadavS/o Devender Singh,Village Ladhuwas Ahir, P.O. Saharanwas,The: Rewari, Haryana - 123401

OBC 05.06.1990

66

Shri Amit Kumar JaiswalS/o Moti Lal JaiswalWard No 3, Dildar Nagar, Ghazipur, UttarPradesh - 232326

OBC 18.07.1992

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

67

Shri Pramod Kumar KS/o Mallappa, Pallavi Book Stall, Surya RaoComplex, R.G. Road, Karatagi (post),Koppal District, Karnataka - 583229

OBC 06.04.1991

68

Shri Puneet KumarS/o Ajab Singh, B-8 Anand Vihar, RakeshMarg, Ghaziabad, Uttar Pradesh - 201001

OBC 21.12.1987

69

Shri Lorance Akhtar SiddiqueS/o Alemul Hoque Village Bhabani Prasad,P.O. Karala, P.S. Dinhata, CoochbeharDist, West Bengal - 736135

OBC 15.12.1992

70

Shri Mahendra SinghS/o Gajraj Singh, H.No. 52Village Chandpur, Ward No 5, POAgriculture School, Bulandshahr, UttarPradesh - 203001

OBC 28.02.1992

71

Shri Mahender ChoudharyS/o Mangilal Choudhary, Near Shiv mandir,Khetanadi, Mandore Road, Jodhpur,Rajasthan - 342007

OBC 06.07.1989

72

Shri Rajesh PS/o Yosepu P, 207-2 Sector-4,Ukkunagaram, Visakhapatnam, AndhraPradesh - 530032

SC 16.04.1988

73

Shri A. Surya BabuS/o Yohan, D.No. 1-12-85, ward-4, ArugulaStreet, Kondavari Peta, Tuni, East Godavaridistrict, Andhra Pradesh - 533401

SC 25.08.1992

74

Shri R. Bharath NayakS/o Babu Rao, H.No.8-78/4/1, Rajeev Nagar, Post Ootpally, MandalBodhan, Nizamabad District, Telangana -503185

ST 08.08.1991

75

Shri Kamatham VinayS/o K Thiripalaiah, 26-1-1014, N.G.O.Colony, B.V. Nagar, Nellore, AndhraPradesh - 524004

SC 26.05.1989

76

Shri D Prakash DeepakS/o Chandra Prakash Flat No. 1585, TypeIII, Delhi Administration Flats, Gulabi Bagh,Delhi - 110007

SC 06.06.1991

77

Ms G. MamathaD/o Martin Rao, D.No.5-6-40/5 NagarjunaNagar, Sattenapalli, Guntur Dist., AndhraPradesh - 522403

SC 03.05.1993

Sl.No NAME OF THE CANDIDATE & ADDRESS CATEGORY DATE OFBIRTH

78

Shri Dhara ViroopS/o D Ramanadhaiah, 1-64/4,Vaishnavi Nagar, Tiruchanoor, Tirupati,Chittoor Dist., Andhra Pradesh - 517503

SC 12.02.1992

79

Shri Rishabh KumarS/o Ramesh Chandra Puraiya, 852 KaliMai, Talpura Jhansi, Uttar Pradesh-284001

SC 30.10.1990

80

Ms Richa KaurD/o K S Mehmi,A-502, New Cosmopolitan CGHS,Plot-33,Sector-10, Dwarka, New Delhi-110075

SC 23.10.1989

81

Ms. SonakshiD/o Arun Kumar,4764/46, Regarpura, Karol Bagh, NewDelhi-110005

SC 20.03.1993

82

Shri Solanki Ravindra MadhukantS/o Solanki Madhukant Nathalal, 17/201,Jawahar nagar, Behind Indira Nagar,Amraiwadi, Ahmedabad, Gujrat-380026

SC 05.01.1986

83

Shri NitishS/o Madan Lal, Simhar House, W.No. 6,Near Naresh Dharam Kanta, Haily Mandi,Pataudi, Gurgaon, Haryana-122504

SC 18.01.1993

84

Shri Mohnish J RangaS/o Jawahar Ranga, 28-A, 3rd Floor, GaliNo. 4, Near Laxmi Gas Agency, RashidMarket, East Delhi-110051

SC 25.02.1986

85

Shri Bhanu Kumar SurepalliS/o Surepalli Deva Kumar, H.No. 74-32-18,Flat No. E1, Sri Sai Residency, Dal MillRoad, Damera Nagar, Vijaywada-520007

SC 17.11.1989

86

Shri Maloth Narasimha RaoS/o Maloth Rekya, H.No. 1-87, BhagwanNaik ,Thanda, Enkoor Mandal, Khammam-507168

ST 30.08.1991

87

Ms.G.SoumyaD/o G.Balram, H.No. 9-6-221, Plot No. 99,Road No. -5, Durga Bhavani Nagar,Champapet, Saidabad, Hyderabad-500059

SC (VH) 11/06/1992

Page 1 of 6

ATTESTATION FORM

PASSPORT SIZEPHOTOGRAPH

WARNING

Affix signed passport size(5 cms x 7 cms approx.copy) ofrecent photograph

1. The furnishing of false information or suppressionof any factual information in the Attestation Formwould be disqualification, and is likely to renderthe candidate unfit for employment under theGovernment.

2. If detained, arrested, prosecuted, bound down,fined convicted, debarred, acquitted etc.subsequent to the completion and submission ofthis form, the details should be communicatedimmediately to the authorities to whom theAttestation Form has been sent early, failing whichit will be deemed to be a suppression of factualinformation.

3. If, the fact that false information has beenfurnished or that there has been suppression of anyfactual information in the Attestation Form comesto notice at any time during the service of a person,his service would be liable to be terminated.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -1. Name in Full NAME SURNAME

(IN BLOCK LETTERS)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -2. Present address in full

(i.e., Village, Thana andDistrict, or House Number,Lane/ Street/ Road and Town)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -3.(a) Home address in full

(i.e. Village, Thana &District or House Number,Lane/Street/ Road & Town andName of the District Hqrs.)

3.(b) If originally a resident of Pakistan/Bangladesh(erstwhile East Pakistan),the address in thatcountry and the date of migration to Indian Union.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

4. Aadhaar Card No.:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

5. PAN Card No.

Page 2 of 6

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

6. Nationality:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

7.(a) Date of Birth :

(b) Present Age :

(c) Age of Matriculation :- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -8. a) Place of birth, District & State :

in which situated

b) District & State to which :you belong

c) District & State to which :your father originally belongs

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -9. a) Your religion :

b) Are you a member of a :Scheduled Caste/ ScheduledTribe/ OBC Answer Yes or No

c) If the answer is Yes, state the name of the Caste thereof:

10. Particulars of places (with periods of residence) where you have resided for more thanone year at a time during the preceding five years. In case of stay abroad (includingPakistan), particulars of all places where you have resided for more than one year afterattaining the age of 21 years, should be given.

FROM TOResidential address in full (i.e Village,Thana & District, or House No., Lane/

Street/Road & Town)

Name of the DistrictHqrs. of the placesmentioned in the

preceding column.

11 Name (in Full &aliases if any)

Nationality(By Birth orby Domicile)

Place of Birth Occupation(if employed,

givedesignationand officeaddress)

PermanentHome

Address

Members ofFamily

1 2 3 4 5

Father

Mother

Page 3 of 6

Spouse

Brother/s

Sister/s

12. Information to be furnished with regard to son(s) and daughter(s) in case they arestudying/living in a foreign country.

Name Nationality(By birth and / or

by domicile)

Place of Birth Country inwhich

studying/living with

full address.

Date from whichstudying/livingin the countrymentioned in

previous column.

13. Educational Qualifications showing places of education with years in Schools & Collegesi.e,. from S.S.C./ Matriculation /10th and onwards:

ExaminationPassed

Name of theSchool/ College

Date ofEntry

Date ofLeaving

Name of Board / University with FullAddress

14 (a) Are you holding or have any time held an appointment under the Central or StateGovernment or a semi-Government or Quasi-Government body or an autonomous body,or a public sector undertaking or a private firm or institution? If so, give full particularswith dates of Employment up-to-date:

PERIOD Designation,Emoluments and

nature of employment

Full name & addressof employer

Reasons for leavingprevious serviceFROM TO

Page 4 of 6

14 (b) If the previous employment was :under the Government of India/a State Govt./ undertaking ownedor controlled by the Govt. of India/State Govt./ an autonomous body/University/Local body:

If you had left service on giving a month’snotice under rule 5 of the Central CivilServices (Temp.Services Rules)1965, or any similar correspondingrules. Were any disciplinaryproceedings framed against you, orhad you been called upon to explainyour conduct in any matter at timeyou gave notice of termination ofservice, or at a subsequent date(s), beforeyour service actually terminated?.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -15(i) Answer in ‘YES or NO’

(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 bound down ? YES / NO

(f) Have you ever been convicted by a Court YES / NO

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/ disqualified by YES / NO

any Public Service Commission/Staff Selection

Commission for any of its examination / Selection ?.

(i) Is any Case pending against you in a YES / NO

Court of Law at the time of filling this

Attestation Form ?

(j) Is any Case pending against you in any YES / NO

University/Institution or any other educational authority/

Institution at the time of filling this

Attestation Form?

(k) Whether discharged/expelled/withdrawn from any training

/Institution under the Government or otherwise? YES / NO

15 (ii) If the answer to any of the above mentioned questions is ‘YES’, give full particulars ofthe case / arrest / detention / fine / conviction / sentence / punishment etc., and or thenature of the case pending in the Court / University/ Educational Authority etc., at thetime of filling this Attestation Form:

Page 5 of 6

(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

‘YES’ or ‘NO’ as the case may be.

16. Name and Address of the two responsiblePersons of your locality or two referencesto whom you are known:

(i). (ii).

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

I certify that the foregoing information is correct and complete to the best of my

knowledge and belief.

I am fully aware that by providing false information or suppressing material information

while filling this form, the authorities have the full right to terminate my appointment letter and I

am also liable for appropriate criminal/civil action as a consequence.

I am not aware of any circumstances, which might impair my fitness for employment

under Government.

Signature of the Candidate

Date :

Place :

Page 6 of 6

IDENTITY CERTIFICATE

Certificate to be signed by any one of the following:

i) Gazetted Officers of Central or State Government :

ii) Members of Parliament or State Legislature :belonging to the Constituency where theCandidate or his parent/ guardian isordinarily residing

iii) Sub Divisional Magistrate/Officer/Block Development Officers :

iv) Tahasildars or Naib/Deputy Tahsildars :authorized to exercise Magisterial Powers

v) Principal/ Head Master of the Recognized :School / College / Institution were the candidateStudied last

vi) Registrar/Deputy Registrar/Assistant Registrar of University :

vii) Post Masters :

viii) Panchayat Inspectors/Mukhiya/Pradhan/Sarpanch :

Certified that I have know 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 & 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

. . . . . . .

C E R T I F I C A T E

Certified that I know Shri/Smt/Kum __________________________________________

Son/ Daughter of Shri _____________________________________________ for the last

____________ years ____________________ months and that to the best of my knowledge and

belief he/she bears a respectable character and has no antecedents which render him/her

unsuitable for Government employment.

Shri / Smt./ Kum. ______________________________________________________ is not

related to me.

Place :

Date :

SIGNATURE AND DESIGNATIONOF THE GAZETTED OFFICER .

C E R T I F I C A T E

Certified that I know Shri/Smt/Kum __________________________________________

Son/ Daughter of Shri _____________________________________________ for the last

____________ years ____________________ months and that to the best of my knowledge and

belief he/she bears a respectable character and has no antecedents which render him/her

unsuitable for Government employment.

Shri / Smt./ Kum. ______________________________________________________ is not

related to me.

Place :

Date :

SIGNATURE AND DESIGNATIONOF THE GAZETTED OFFICER .

NOTE: To be signed by two different Gazetted Officers and to be attested by a DistrictMagistrate or Sub Divisional Magistrate or their superior officers.

ANNEXURE – IICANDIDATE’S STATEMENT AND DECLARATION

The candidate must fill the below columns prior to his/her Medical Examination andmust sign the declaration appended thereto. His/her attention is specifically drawn to thewarning contained in the NOTE below:

1. State your name in full :(In Block Letters)

2. State your age and place of Birth :

3. (a) Have you ever had small-pox intermitten :or any other fever enlargement or suppruationof glands spitting of blood, asthama heartdisease, lung disease, fainting attacks,rheumatism, appendicitis ? OR.

(b) any other disease or accident requiring :confinement to bed and medical or surgicaltreatment.

4. When were you last vaccinated :

5. Have you or any of your near relations been :affected with Consumption of Orofula, gout,asthama, fits epilepsy or insanity.

6. Have you been examined and declared Unfit :for Govt. Service by a Medical Officer/ MedicalBoard within last 3 years.

7. Have you suffered from any form of Nervousness :due to overwork or any other cause.

8. Furnish the following particulars Concerning :your family

Father’s age if Livingand state of hishealth

Father’s age at thetime of death and thecause of his death

No. of brothersliving, their age &state of health

No. of brothers deadtheir ages at death &causes of death.

I declare that all the particulars filled in the above columns are true and correct to the bestof my knowledge and belief.

I also solemnly affirm that I have not received a disability certificate/pension on accountof any disease or other conditions.

Signed in my presenceSIGNATURE OF THE CANDIDATE

SIGNATURE OF THE MEDICAL OFFICER

NOTE: The candidate will be held Responsible for the accuracy of the above statement, willfulsuppression of any information by the candidate will incur the risk of losing the appointment andif appointed forfeiting of all claims of Superannuating pension and Gratuity.

CERTIFICATE OF PHYSICAL FITNESS

I have carefully examined Sri/Smt ____________________________________________

S/o/D/o/ W/o ______________________________________________________ a candidate for

Employment under the Government of India, Central Excise Department as

_______________________ and cannot discover that he/she has any disease, communicable or

otherwise constitutional affection or bodily infirmity except that his/her weight is in

excess/below the standard prescribed or except ___________________________ I do not

consider this a disqualification for the employment in the office of the Central Excise

Department.

I do further certify that in my opinion his/ her general physical condition is such that it

will enable him/her to perform the duties of executive services efficiently.

His/her age according to his/ her own statement is _______________ years and by

appearance about ______________ years, I also certify that he has make of small pos

vaccination.

He/she is FREE FROM ANY COMMUNICABLE DISEASE.

Chest Measurement in Cms:

On full inspiration :

On full expiration :

Height ______________________ Weight ______________

His/ her vision is normal _____________________________________________

Hypermetrophic (______________________________________________________)Enter the degree of defect and the strength of correction glasses

Myopic (____________________________________________________________)Enter the degree of defect and the strength of correction glasses

Astigmatic (Simple or mixed (___________________________________________)Here enter the degree of defect and strength of correction glasses.

Hearing is normal/defective (much or slight)

Urine: Does Chemical examination show 1. Albumin, 2. Sugar, 3. State specific gravity

Personal Marks of Identification :

1.

2.

SIGNATURE OF THE MEDICAL OFFICER

Date :

Place :SIGNATURE OF THE CANDIDATE

ANNEXURE – III

DECLARATION TO BE OBTAINED FROM NEW ENTRANTS TO THE GOVERNMENTSERVICE

I Shri/Smt/Kum __________________________________________________________

Declare as under:

(1)* That I am un-married/ a widower/ a widow

(2)* That I am married and have only one spouse living

(3)* That I have entered in to or contracted a marriage with a person having a spouseliving Application for grant of exemption is enclosed.

(4)* That I have entered into and contracted a marriage with another person during thelife time of my spouse. Application for grant of exemption is enclosed.

I solemnly affirm that the above declaration is true and I understand that in the event ofthe declaration being found to be incorrect after my appointment I shall be liable to be dismissedfrom service.

Place :

Date :SIGNATURE OF THE CANDIDATE

• Please strike out the clause/ clauses not applicable.