ANNEXURE - I

TERMS AND CONDITIONS OF APPOINTMENT OF SUPERVISOR TRAINEE

1. You will undergo training for a period of ONE YEAR which may be extended at the discretion of
the Company.

2. During the training period, you will be placed at the minimum of the grade mentioned in the offer
of appointment. Dearness allowance will be paid as per company rules. You will also be entitled to
a fixed “Cafeteria” perks limited to 46 % of your Basic Pay.

3. Hostel accommodation, which will be free of charge, will be provided wherever available. HRA
will be paid as admissible under Normal Rules, where hostel accommodation is not provided.
However, no HRA will be admissible if hostel accommodation is provided, but not availed.

4. You will be entitled to other benefits such as Leave, Medical and Performance Related Payment
etc. as per Company rules. Superannuation benefits comprising Contributory Provident Fund,
Gratuity, Pension and Post Retirement Medical Benefits are also admissible as per Company
Rules.

5. At the end of the training, your suitability for absorption will be evaluated on the basis of a
written test and / or interview. The decision of the company regarding your suitability for
absorption shall be final.

6. If you fail to successfully complete the training at the end of one year training either due to your
failure to secure required attendance or on account of your failing to qualify in the written test
and / or interview, the training will be extended by a period of six months at the end of which you
are required to appear again for the written test and / or interview after satisfying the attendance
requirement during the extended period. If you again fail to qualify in the manner as aforesaid,
the training will be further extended by a period of six months at the end of which you are again
required to appear for the written test and / or interview after satisfying the attendance
requirement during the second extended period.

7. If you fail to successfully complete the training at the end of the second extended period as
specified in Clause 6, your services shall be terminated by BHEL forthwith without notice.

8. After successful completion of the training, you will be absorbed as Assistant Engineer Grade II.
Your placement in an appropriate area and posting to any of the Company's offices, divisions or
any other department or undertaking of the Govt. Of India in India or abroad will be at the
discretion of the management.

9. You will be on probation for a period of one year from the date of absorption. Extension of the
probation period will depend upon performance. Termination of service during this period may
be the extreme Management decision.

10. You will be allowed 1st Class/2nd AC train fare for yourself, spouse and dependent children from
your starting station or your hometown whichever is nearer to your place of posting for the
purpose of joining. For reimbursement please bring the enclosed proforma Annexure VI duly
filled in at the time of joining.
 AA: ETX: ETP 8: R0: 12/09

¼ããÀ¦ã ÖñÌããè ƒÊãñãä‡ã‹›È‡ãŠÊÔã ãäÊããä½ã›ñ¡

BHARAT HEAVY ELECTRICALS LIMITED
____________________________ ¹ããäÀãäÍãÓ› - VII
ANNEXURE - VII

Ôããà¾ãâ‡ãŠ¶ã ¹ã¨
ATTESTATION FORM

I. Þãñ¦ããÌã¶ããè Ôããà¾ãâ‡ãŠ¶ã ¹ã¨ã ½ãò ¢ãîŸãè •ãã¶ã‡ãŠãÀãè ªñ¶ãã ¾ãã ãä‡ãŠÔããè ¦ã©¾ã ‡ãŠãñ ã䜹ãã¶ãã ‚ã¾ããñؾã¦ãã ÖãñØããè ‚ããõÀ „½½ããèªÌããÀ ‡ãŠãñ ÔãÀ‡ãŠãÀãè ¶ããõ‡ãŠÀãè
¹ãã¶ãñ ‡ãñŠ ãäÊㆠ‚ã¾ããñؾã ÜããñãäÓã¦ã ãä‡ãŠ¾ãã •ãã Ôã‡ãŠ¦ãã Öõ ý
Affix passport size (5X7)
WARNING The furnishing of false information or suppression of any factual information in the Attestation form would photograph duly attested
be a disqualification, and is likely to render the candidate unfit for employment under the Government. by a gazetted officer

II. ¾ããäª ƒÔã ¹ãŠã½ãà ‡ãŠãñ ¼ãÀ‡ãŠÀ ªããäŒãÊã ‡ãŠÀ¶ãñ ‡ãñŠ ºã㪠„½½ããèªÌããÀ À•ãÀºãâª, ãäØãÀ¹ã‹¦ããÀ ãä‡ãŠ¾ãã Øã¾ãã Öãñ, ½ãì‡ãŠª½ãã ÞãÊãã Öãñ, ½ãìÞãÊã‡ãñŠ, •ãì½ããöãã ¾ãã
Ôã•ãã ÖìƒÃ Öãñ ¦ããñ ÌãÖ ƒÔã Ôãâºãâ£ã ½ãò º¾ããõÀñ ¦ã¦‡ãŠãÊã „Ôã ‚ããä£ã‡ãŠãÀãè ‡ãŠãñ ¼ãñ•ãñØãã ãä•ãÔãñ ¹ãÖÊãñ Ôããà¾ãâ‡ãŠ¶ã ¹ã¨ã ¼ãñ•ãã Øã¾ãã Öõ, †ñÔã㠶㠇ãŠÀ¶ã㠦㩾ããò
‡ãŠãñ ã䜹ãã¶ãã Ôã½ã¢ãã •ãã†Øãã / If detained, arrested, prosecuted, bound down, fined, convicted, debarred, acquitted etc.
subsequent to the completion and submission of this form, the detils 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.

III. ¾ããäª ãä‡ãŠÔããè ̾ããä‡ã‹¦ã ‡ãñŠ ÔãñÌãã‡ãŠãÊã ‡ãñŠ ªãõÀã¶ã ãä‡ãŠÔããè ¼ããè Ôã½ã¾ã ƒÔ㠦㩾㠇ãŠãè •ãã¶ã‡ãŠãÀãè ãä½ãÊã¦ããè Öõ ãä ‡ãŠ Ôããà¾ãâ‡ãŠ¶ã-¹ã¨ã ½ãò ¢ãîŸãè •ãã¶ã‡ãŠãÀãè ªãè ØãƒÃ Öõ ¾ãã ãä‡ãŠÔããè ¼ããè ¦ã©¾ã¹ãî¥ãÃ
•ãã¶ã‡ãŠãÀãè ‡ãŠãñ ã䜹ãã¾ãã Øã¾ãã Öõ ¦ããñ †ñÔãñ ̾ããä‡ã‹¦ã ‡ãŠãè ÔãñÌãã Ôã½ã㹦㠇ãŠãè •ãã Ôã‡ãñŠØããè / If the fact that false information has been furnished or that there has benn
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 the terminated.

IV. ¹ãƦ¾ãñ‡ãŠ ¹ãÆͶ㠇ãñŠ ãäÊㆠ"Öãâ" ¾ãã "¶ãÖãé" ¹ãÀ ãä¶ãÍãã¶ã ÊãØãã‡ãŠÀ •ãõÔãã ÊããØãî Öãñ, „¦¦ãÀ ã䪾ãñ •ãã¶ãñ ÞãããäÖ† / Specific answer to each of the question should be given by
striking 'Yes or No' as the case may be.
1. ¹ãîÀã ¶ãã½ã „¹ã¶ãã½ã ÔããäÖ¦ã, ¾ããäª Öãñ ¦ããñ / ‡ãìŠÊã ¶ãã½ã ¶ãã½ã
Name in full (in block capitals) with aliases, if any SURNAME NAME

( ‡ãðŠ¹ã¾ãã ºã¦ãã†â ¾ããäª ‚ã¹ã¶ãñ ¶ãã½ã ¾ãã ‡ãìŠÊã ¶ãã½ã ‡ãñŠ ãä‡ãŠÔããè ¼ããè ¼ããØã ½ãò ãä‡ãŠÔããè ¼ããè Ôã½ã¾ã ‡ã슜 •ããñü¡ã ¾ãã œãñü¡ã Öãñý / Please indicate if you have added or dropped in any
stage any part of your name or surname)

2. ¹ãîÀã Ìã¦ãýãã¶ã ¹ã¦ãã (‚ã©ããæã ØãÆã½ã, ©ãã¶ãñ ‚ããõÀ ãä•ãÊãñ ‡ãŠã ¶ãã½ã ¾ãã ½ã‡ãŠã¶ã ¶ã½ºãÀ/ØãÊããè/Ôãü¡‡ãŠ/Àãñü¡ ‚ããõÀ ¶ãØãÀ) / Present address in full (i.e. Village, Thana, and District
or House No. Lane/Strret/Road and Town)

3. (‡ãŠ/a) ÜãÀ ‡ãŠã ¹ãîÀã ¹ã¦ãã (‚ã©ããæã ØãÆã½ã, ©ãã¶ãñ ‚ããõÀ ãä•ãÊãñ ‡ãŠã ¶ãã½ã ¾ãã ½ã‡ãŠã¶ã ¶ã½ºãÀ/ØãÊããè/Ôãü¡‡ãŠ/Àãñü¡ ¦ã©ãã ¶ãØãÀ ¦ã©ãã ãä•ãÊãã ½ã쌾ããÊã¾ã ‡ãŠã ¶ãã½ã ) Home Address in full
(i.e. Village, Thana, and District or House No. Lane/Strret/Road and Town and name of District Headquarters.)
 (Œã/b) ¾ããäª ½ãîÊã¦ã: ¹ãããä‡ãŠÔ¦ãã¶ã ‡ãñŠ ãä¶ãÌããÔããè Öãñ ¦ããñ „Ôã ªñÍã ‡ãŠã ¹ã¦ãã ‚ããõÀ ¼ããÀ¦ã ÔãâÜã ½ãò ¹ãÆÌããÔã ‡ãŠãè ¦ããÀãèŒã /If originally a resident of Pakistan the address in that
country and the date of migration to Indian Union.

4. ãä¹ãœÊãñ ¹ããâÞã ÌãÓããô ‡ãñŠ ªãõÀã¶ã, †ñÔãñ Ô©ãã¶ããò ‡ãñŠ º¾ããõÀñ (ãä¶ãÌããÔã ‡ãŠãè ‚ãÌããä£ã ÔããäÖ¦ã) ªãèãä•ã†, •ãÖãâ ‚ãã¹ã †‡ãŠ ºããÀ ½ãò †‡ãŠ ÌãÓãà Ôãñ ‚ããä£ã‡ãŠ Ôã½ã¾ã ¦ã‡ãŠ ÀÖ Þãì‡ãñŠ Öãò ý ãäÌãªñÍã (¹ãããä‡ãŠÔ¦ãã¶ã)
½ãò ãä¶ãÌããÔã ‡ãŠÀ¶ãñ ‡ãŠãè ªÍãã ½ãò, †ñÔãñ Ô©ãã¶ããò ‡ãñŠ º¾ããõÀñ ã䪾ãñ •ãã¶ãñ ÞãããäÖ† •ãÖãâ ‚ãã¹ã 21 ÌãÓãà ‡ãŠãè ‚ãã¾ãì ¹ãÆ㹦㠇ãŠÀ¶ãñ ‡ãñŠ ºã㪠†‡ãŠ ÌãÓãà Ôãñ ‚ããä£ã‡ãŠ Ôã½ã¾ã ¦ã‡ãŠ ÀÖñ Öãò / Particulars of
places (with periods 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) of all places where you have resided for more than one year attaining the age of 21 years, should be given.

Ôãñ/From ¦ã‡ãŠ/to ãä¶ãÌããÔã ‡ãŠã ¹ãîÀã ¹ã¦ãã (‚ã©ããæã ØãÆã½ã, ãä¹ãœÊãñ ‡ãŠãÊã½ã ½ãò Ìããä¥ãæã
©ãã¶ãñ ‚ããõÀ ãä•ãÊãñ ‡ãŠã ¶ãã½ã ¾ãã ½ã‡ãŠã¶ã Ô©ãã¶ã ‡ãñŠ ãä•ãÊãã ½ã쌾ããÊã¾ã
¶ã½ºãÀ/ØãÊããè/Ôãü¡‡ãŠ ‚ããõÀ ¶ãØãÀ) ‡ãŠã ¶ãã½ã /
Residential address in full (i.e. Village, Name of the District Headquarters of
Thana and District or and Town) the place mentioned in the preceding col.

SNo From To Residential Address District Headquarters

5.
Occupation (if
Nationality (by employed give
Present postal Permanent
SNo Relation Name birth/or by Place of birth designation &
address home address
domicile) official
address)
1 Father

2 Mother

3 Spouse

4 Brother (s)

8 Sister(s)

10
6.(‡ãŠ/a) ‚ã¹ã¶ãñ †ñÔãñ ¹ãì¨ã (¹ãì¨ããò) ‚ããõÀ/¾ãã Êãü¡‡ãŠãè (Êãü¡ãä‡ãŠ¾ããò) ‡ãñŠ Ôãâºãâ£ã ½ãò •ãã¶ã‡ãŠãÀãè ªãèãä•ã† •ããñ ãäÌãªñÍã ½ãò ¹ãü¤ ÀÖñ Öãò/ÀÖ ÀÖñ Öãòý / Information to be furnished with regard
to son(s) and/or daughter(s) in case they are studying in a foreign country.

¶ãã½ã Name ____________________________________________________

ÀãÓ›Èãè¾ã¦ãã(•ã¶½ã Ôãñ ‚ããõÀ/¾ãã ¹ãÆÌããÔããè Öãñ¶ãñ Ôãñ)/ Nationality (by birth and/or by domicile) ______________________________________________

•ã¶½ã Ô©ãã¶ã / Place of birth ______________________________________________

„Ôã ªñÍã ‡ãŠã ¶ãã½ã ¹ãîÀñ ¹ã¦ãñ ÔããäÖ¦ã/•ãÖãâ ¹ãü¤ ÀÖñ/ÀÖ ÀÖñ Öãò / Country in which studying/living with full address ________________________________________

¹ãÖÊãñ ‡ãŠãÊã½ã ½ãò Ìããä¥ãæ㠪ñÍã ½ãò ãä‡ãŠÔã ¦ããÀãèŒã Ôãñ ¹ãü¤ ÀÖñ/ÀÖ ÀÖñ Öãò / Date from which studying living in the country mentioned in previous column.____________

7. Date of birth _______________________________________________________

Ìã¦ãýãã¶ã ‚ãã¾ãì /Present age _______________________________________________________

½ãõãä›È‡ãŠ ¹ããÔã ‡ãŠÀ¶ãñ ‡ãñŠ Ôã½ã¾ã ‚ãã¾ãì / Age at Matriculation ______________________________________________

8. •ã¶½ã Ô©ãã¶ã, ãä•ãÊãã ‚ããõÀ À㕾㠇ãŠã ¶ãã½ã •ãÖãâ ãäÔ©ã¦ã Öãò / Place of birth, District and State in which situated _______________________________________

ãä•ãÊãã ‚ããõÀ À㕾㠕ãÖãâ ‡ãñŠ ‚ãã¹ã ÀÖÊãñ ÌããÊãñ Öö / District and State to which you belong __________________________________________________________

ÌãÖ ãä•ãÊãã ‚ããõÀ À㕾㠕ãÖãâ ‡ãñŠ ‚ãã¹ã‡ãñŠ ãä¹ã¦ãã ½ãîÊã¦ã: ÀÖÊãñ ÌããÊãñ Öö / District and State to which your father originally belongs ______________________________

9. ‚ãã¹ã ‡ãŠã £ã½ãà / Your religion ______________________________

‡ã‹¾ãã ‚ãã¹ã ‚ã¶ãìÔãìãäÞã¦ã •ãããä¦ã/•ã¶ã•ãããä¦ã ‡ãñŠ Öö ? „¦¦ãÀ "Öãâ" ¾ãã "¶ãÖãé" ½ãò ªãèãä•ã† / Are you a member od Scheduled Caste/Scheduled Tribe? Answer 'Yes' or 'No'
10. 15 ÌãÓãà ‡ãŠãè ‚ãã¾ãì ‡ãñŠ ¹ãÍÞãã¦ãá „¶ã Íãõàããä¥ã‡ãŠ Ô©ãã¶ããò ‡ãñŠ ¶ãã½ã, ÌãÓãà ÔããäÖ¦ã ãäÊãŒãò ãä•ã¶ã Ô‡ãîŠÊããò ‚ããõÀ ‡ãŠãÊãñ•ããò Ôãñ Íãõãäàããä¥ã‡ãŠ ¾ããñؾã¦ãã†â ¹ãÆ㹦㠇ãŠãè Öö / Educational
Qualifications showing places of education with years in Schools and Colleges since 15th year of age.
¹ãîÀñ ¹ã¦ãñ ÔããäÖ¦ã Ô‡ãîŠÊã / ‡ãŠãÊãñ•ã ‡ãŠã ¶ãã½ã ¹ãÆÌãñÍã ‡ãŠãè ¦ããÀãèŒã œãñü¡¶ãñ ‡ãŠãè ¦ããÀãèŒã „¦¦ããè¥ãà ¹ãÀãèàãã
Name of School/ Date of Date of Examinations
College with full address entering leaving passed

Name of School/ Date of Date of

Examinations passed
College with full address entering leaving

11. (‡ãŠ/a) ‡ã‹¾ãã ‚ãã¹ã ‡ãñŠ¶³ãè¾ã ¾ãã À㕾ã ÔãÀ‡ãŠãÀ ¾ãã ãä‡ãŠÔããè ‚ã£ãÃ-ÔãÀ‡ãŠãÀãè ¾ãã ÔãÀ‡ãŠãÀãèÌã¦ãá ãä¶ã‡ãŠã¾ã ¾ãã ÔÌãã¾ã¦ã ãä¶ã‡ãŠã¾ã ¾ãã ÔãÀ‡ãŠãÀãè „¹ã‰ãŠ½ã ¾ãã ãä¶ã•ããè ¹ãŠ½ãà ¾ãã ¹ãÆãä¦ãÓŸã¶ã ½ãò ¶ããõ‡ãŠÀãè
‡ãŠÀ ÀÖñ Öö ¾ãã ãä‡ãŠÔããè ¼ããè Ôã½ã¾ã ‡ãŠÀ Þãì‡ãñŠ Öö ? ¾ããäª †ñÔãã Öõ ¦ããñ ‚ã¼ããè ¦ã‡ãŠ ‡ãŠãè ¶ããõ‡ãŠÀãè ‡ãñŠ ¹ãîÀñ º¾ããõÀñ ¦ããÀãèŒããò Ôããä֦㠪ãèãä•ã† / 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 date of employment up-to-date.

‚ãÌããä£ã ¹ãª, Ìãñ¦ã¶ã ‚ããõÀ ãä¶ã¾ããñ‡ã‹¦ãã ‡ãŠã ¹ãîÀã ¶ãã½ã ‚ããõÀ ¹ã¦ãã ãä¹ãœÊããè ¶ããõ‡ãŠÀãè œãñü¡¶ãñ ‡ãŠã ‡ãŠãÀ¥ã
Period ãä¶ã¾ããñ•ã¶ã ‡ãŠã ÔÌãÁ¹ã Full Name & address of employer Reasons for leaving previous service
Ôãñ ¦ã‡ãŠ Designation, employment
and nature of employment
From To
 Designation, employment Full Name & address of Reasons for leaving
From To
and nature of employment employe previous service

11. (Œã/b) ‡ã‹¾ãã ãä¹ãœÊããè ¶ããõ‡ãŠÀãè ¼ããÀ¦ã ÔãÀ‡ãŠãÀ/À㕾ã ÔãÀ‡ãŠãÀ/¼ããÀ¦ã ÔãÀ‡ãŠãÀ ¾ãã À㕾ã ÔãÀ‡ãŠãÀ ‡ãñŠ ÔÌãããä½ã¦Ìã ¾ãã ãä¶ã¾ãâ¨ã¥ã ½ãò ÔãâÞãããäÊã¦ã „¹ã‰ãŠ½ã ÔÌãã¾ã¦ã
ãä¶ã‡ãŠã¾ã/ãäÌãÍÌããäÌã²ããÊã¾ã/Ô©ãã¶ããè¾ã ãä¶ã‡ãŠã¾ã ‡ãñŠ ‚ã£ããè¶ã ©ããè? ‡ã‹¾ãã ‚ãã¹ã¶ãñ ‡ãñŠ¶³ãè¾ã ãäÔããäÌãÊã ÔãñÌãã (‚ãÔ©ãã¾ããè ÔãñÌãã) ãä¶ã¾ã½ã, 1965 ‡ãñŠ ãä¶ã¾ã½ã 5 ¾ãã ãä‡ãŠ¶Öãé Ôã½ãã¶ã ÔãâØã¦ã ãä¶ã¾ã½ããò ‡ãñŠ ‚ã£ããè¶ã
†‡ãŠ ½ããÖ ‡ãŠãè ÔãîÞã¶ãã ªñ‡ãŠÀ ¶ããõ‡ãŠÀãè œãñü¡ãè ©ããè? ‡ã‹¾ãã ‚ãã¹ã‡ãŠãè ÔãñÌãã†â ¾ã©ããÜã¦ã Ôã½ã㹦ã ãä‡ãŠ¾ãñ •ãã¶ãñ ‡ãñŠ ¹ãîÌãÃ, ‚ãã¹ã‡ãñŠ ãäÌãÁ® ‡ãŠãñƒÃ ‚ã¶ãìÍããÔããä¶ã‡ãŠ ‡ãŠã¾ãÃÌããÖãè ‡ãŠãè ØãƒÃ ©ããè ¾ãã ‚ãã¹ã‡ãŠãè ÔãñÌãã†â
Ôã½ã㹦㠇ãŠÀ¶ãñ Ôãâºãâ£ããè ¶ããñãä›Ôã ªñ¶ãñ ¹ãÀ ¾ãã „Ôã‡ãñŠ ºã㪠‡ãŠãè ¦ããÀãèŒã ‡ãŠãñ ãä‡ãŠÔããè ¼ããè ãäÌãÓã¾ã ½ãò ‚ãã¹ã‡ãŠãñ ‚ã¹ã¶ãã ‚ããÞãÀ¥ã Ô¹ãÓ› ‡ãŠÀ¶ãñ ‡ãñŠ ãäÊㆠ‚ããªñÍã ã䪾ãã Øã¾ãã ©ãã? ¾ããäª Öãâ ¦ããñ ‡ãðŠ¹ã¾ãã
ãäÌãÌãÀ¥ã ªò / If the previous employment was under the Govt. of India/State Govt./ an undertaking owned or controlled by the Govt. of India or State
Govt./ an autonoms body/University/Local body. If you had left service on giving a month's notice under rule 5 of the Central Civil Services
(Temporary Services) 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 have notice or termination of service, or at a subsequent date, before your services
actually terminated? If yes, please furnish details.
12.
(‡ãŠ) ‡ã‹¾ãã ‚ãã¹ã ãäØãÀ¹ã‹¦ããÀ ãä‡ãŠ¾ãñ Øã¾ãñ? Öãâ/¶ãÖãé
(a) Have you ever been arrested? Yes/No

(Œã) ‡ã‹¾ãã ‚ãã¹ã ¹ãÀ ‡ãŠ¼ããè ‚ããä¼ã¾ããñØã ÊãØãã¾ãã Øã¾ãã? Öãâ/¶ãÖãé

(b) Have you ever been prosecuted? Yes/No

(Øã) ‡ã‹¾ãã ‚ãã¹ã‡ãŠãñ ‡ãŠ¼ããè ¶ã•ãÀºã¶ª ãä‡ãŠ¾ãã Øã¾ãã? Öãâ/¶ãÖãé

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

(Üã) ‡ã‹¾ãã ‚ãã¹ã‡ãŠãñ ‡ãŠ¼ããè ½ãìÞãÊã‡ãñŠ ãä‡ãŠ¾ãñ Øã¾ãñ? Öãâ/¶ãÖãé

(d) Have you ever been bound down? Yes/No

(¡.) ‡ã‹¾ãã ‚ãã¹ã ¹ãÀ ‡ãŠ¼ããè ãä‡ãŠÔããè ¶¾ãã¾ããÊã¾ã ´ãÀã •ãì½ããöãã ãä‡ãŠ¾ãã Øã¾ãã? Öãâ/¶ãÖãé
(e) Have you ever been fined by a Court of Law? Yes/No

(Þã) ‡ã‹¾ãã ‚ãã¹ã ‡ãŠ¼ããè ¼ããè ãä‡ãŠÔããè ‚ã¹ãÀã£ã ‡ãñŠ ãäÊã¾ãñ ¶¾ãã¾ããÊã¾ã ´ãÀã ªâã䡦ã ãä‡ãŠ¾ãñ Øã¾ãñ? Öãâ/¶ãÖãé
(f) Have you ever been convicted by a Court of Law for any offence? Yes/No

(œ) ‡ã‹¾ãã ‚ãã¹ã ‡ãŠ¼ããè ãä‡ãŠÔããè ¹ãÀãèàãã Ôãñ Ìããä•ãæã ãä‡ãŠ¾ãñ Øã¾ãñ ¾ãã ãä‡ãŠÔããè ãäÌãÍÌããäÌã²ããÊã¾ã ¾ãã ãä‡ãŠÔããè ‚ã¶¾ã Íãõàããä¥ã‡ãŠ ¹ãÆããä£ã‡ãŠãÀãè/ÔãâÔ©ãã ´ãÀã ãä¶ãÓ‡ãŠããäÔã¦ã ãä‡ãŠ¾ãñ Øã¾ãñ? Öãâ/¶ãÖãé
(g) Have you ever been debarred from any nomination or rusticated by any University or any other educational authority/institution? Yes/No

(•ã) ‡ã‹¾ãã ‚ãã¹ã ‡ãŠ¼ããè Êããñ‡ãŠ ÔãñÌãã ‚ãã¾ããñØã ´ãÀã „Ôã‡ãŠãè ãä‡ãŠÔããè ¼ããè ¹ãÀãèàãã/Þã¾ã¶ã ‡ãñŠ ãäÊã¾ãñ Ìããä•ãæã/‚ã¾ããñ ؾ㠟ÖÀã¾ãñ Øã¾ãñ? Öãâ/¶ãÖãé
(h) Have you ever been debarred/disqulaified by any Public service Commission/Staff Selection Commission for any of its examination/selection?
YEs/No

(¢ã) ‡ã‹¾ãã ‚ãã¹ã Ôããà¾ãâ‡ãŠ¶ã ¹ã¨ã ¼ãÀ¶ãñ ‡ãñŠ Ôã½ã¾ã ‚ãã¹ã‡ãñŠ ãäÌãÁ® ‡ãŠãñƒÃ ½ãã½ãÊãã, ãä‡ãŠÔããè ¶¾ãã¾ããÊã¾ã ½ãò ÞãÊã ÀÖã Öõ? Öãâ/¶ãÖãé
(i) Is any case pending againseyou in any Court of law at the time of filling up this Attestation Form? Yes/No

(ii) ¾ããäª …¹ãÀ Ìããä¥ãæã ãä‡ãŠ¶Öãé ¼ããè ¹ãÆͶããò ‡ãŠã „¦¦ãÀ 'Öãâ' ½ãò Öãñ ¦ããñ ½ãã½ãÊãã, ãäØãÀ¹ã‹¦ããÀãè/¶ã•ãÀºãâªãè/ •ãì½ããöãã/‚ããä¼ã¾ããñ•ã¶ã/Ôã•ãã/ªâ¡ ‚ãããäª ‡ãñŠ Ôãâºãâ£ã ½ãò ‚ããõÀ ¾ãã ƒÔã ¹ãŠã½ãà ‡ãñŠ ¼ãÀ¶ãñ ‡ãñŠ
Ôã½ã¾ã ãä‡ãŠÔããè ¶¾ãã¾ããÊã¾ã/ãäÌãÍÌããäÌã²ããÊã¾ã/Íãõàããä¥ã‡ãŠ ‚ããä£ã‡ãŠãÀãè ‚ãããäª ‡ãñŠ Ôã½ãàã ÞãÊã ÀÖñ ½ãã½ãÊãñ ‡ãñŠ Ôãâºãâ£ã ½ãò ¹ãîÀñ º¾ããõÀñ ªãèãä•ã¾ãñ / If the answer to any of the above mentioned
questions is Yes, give full particulars of the case/arrest/detention/fine conviction/sentence/punishment etc. and/or the nature of the case pending in the
Court/University/Educational Authority etc, at the time of filling up this form.

13. ‚ã¹ã¶ãñ Ô©ãã¶ããè¾ã †ñÔãñ ªãñ ãä•ã½½ãñªãÀ ¾ãã †ñÔãñ ªãñ ̾ããä‡ã‹¦ã¾ããò ‡ãñŠ ¶ãã½ã †Ìãâ ¹ã¦ãñ ªãèãä•ã† ãä•ã¶Öò ‚ãã¹ã •ãã¶ã¦ãñ Ööý/ Name and address of two responsible persons of your
locality or two reference to whom you are known:

Reference - 1 Reference - 2

½ãö ¹ãƽãããä¥ã¦ã ‡ãŠÀ¦ãã/‡ãŠÀ¦ããè Öîú ãä‡ãŠ ½ãñÀñ ÔãÌããó¦¦ã½ã —ãã¶ã †Ìãâ ãäÌãÍÌããÔã ‡ãñŠ ‚ã¶ãìÔããÀ …¹ãÀ ªãè ØãƒÃ •ãã¶ã‡ãŠãÀãè ÔãÖãè Öõ ‚ããõÀ ¹ãî¥ãà Öõ ½ãì¢ãñ †ñÔããè ãä‡ãŠÔããè ¼ããè ºãã¦ã ‡ãŠãè •ãã¶ã‡ãŠãÀãè ¶ãÖãé Öõ •ããñ
ÔãÀ‡ãŠãÀãè ¶ããõ‡ãŠÀãè ‡ãñŠ ãäÊㆠ½ãñÀãè „¹ã¾ãì‡ã‹¦ãã ½ãò ºãã£ã‡ãŠ Öãñ / I certify that the foregoing information is correct and complete to the best of my knowledge and beleif. I
am not aware of any circumstances which might impair my fitness for employment under Government.

„½½ããèªÌããÀ ‡ãñŠ ÖÔ¦ããàãÀ / Signature of Candidate ..................................

ã䪶ããâ‡ãŠ / Date .....................................................................

Ô©ãã¶ã / Place .....................................................................

 ¹ãÖÞãã¶ã ¹ãƽãã¥ã - ¹ã¨ã / IDENTITY CERTIFICATES

(¹ãƽãã¥ã¹ã¨ã ãä¶ã½¶ããäÊããäŒã¦ã ½ãò Ôãñ ãä‡ãŠÔããè †‡ãŠ ‡ãñŠ ´ãÀã ÖÔ¦ããàããäÀ¦ã Öãñ¶ãã ÞãããäÖ† / Certificate to be signed by any one of the following)

 ‡ãñŠ¶³ãè¾ã ¾ãã À㕾ã ÔãÀ‡ãŠãÀ ‡ãñŠ Àã•ã¹ããä¨ã¦ã ‚ããä£ã‡ãŠãÀãè / Gazetted officers of Central or State Government;
 ÔãâÔ㪠¾ãã À㕾ã ãäÌã£ãã¶ã Ôã¼ãã ‡ãñŠ †ñÔãñ ãä¶ãÌããÃÞã¶ã àãñ¨ã ‡ãñŠ ÔãªÔ¾ã •ãÖãâ ‡ãŠã ÔÌã¾ãâ „½½ããèªÌããÀ ¾ãã „Ôã‡ãñŠ ½ãã¦ãã ãä¹ã¦ãã/ÔãâÀàã‡ãŠ Ôãã½ã㶾ã ãä¶ãÌããÔããè Öãò / Members of
Parliament or State Legislature belonging to the Constituency where the candidate of his parent/guardian is ordinarily resident;
 Ôãºã-ãä¡Ìããè•ã¶ãÊã ½ããä•ãÔ›Èñ›/‚ããä£ã‡ãŠãÀãè / Sub-Divisional Magistrates/Officers;
 ¦ãÖÔããèÊãªãÀ ¾ãã ¶ãã¾ãºã/ã䡹›ãè ¦ãÖÔããèÊãªãÀ •ããñ ½ããä•ãÔ›Èñ›ãè ‚ããä£ã‡ãŠãÀãò ‡ãñŠ ¹ãƾããñØã ‡ãŠÀ¶ãñ ‡ãñŠ ãäÊㆠ¹ãÆããä£ã‡ãðŠ ¦ã Öãò / Tehsildars or Naib/Deputy authorised to exercise
magisterial power;
 ½ã㶾ã¦ãã ¹ãÆ㹦ã Ô‡ãîŠÊã/‡ãŠãÊãñ•ã/ÔãâÔ©ãã¶ã ‡ãñŠ ãä¹ãÆâÔããè¹ãÊã/¹ãÆ£ãã¶ã㣾ãã¹ã‡ãŠ •ãÖãâ „½½ããèªÌããÀ ¶ãñ ‚ãã䶦ã½ã ¹ãü¤ãƒÃ ‡ãŠãè Öãñ /Principal/HEad/Master of the recognised
School/College/Institution where the candidates studied last;
 Œãâ¡ ãäÌã‡ãŠãÔã ‚ããä£ã‡ãŠãÀãè / Block Development Officer;
 ¹ããñÔ› ½ããÔ›À / Post-Masters;
 ¹ãâÞãã¾ã¦ã ãä¶ãÀãèàã‡ãŠ / Panchayat Inspectors.
¹ãƽãããä¥ã¦ã ãä‡ãŠ¾ãã •ãã¦ãã Öõ ãä‡ãŠ ½ãö Ñããè/Ñããè½ã¦ããè/‡ã슽ããÀãè .................................... ¹ãì¨ã/¹ã¦¶ããè/¹ãì¨ããè ............ ...........‡ãŠãñ Øã¦ã .......................ÌãÓãÃ
........................½ããÖ ....................... Ôãñ •ãã¶ã¦ãã/•ãã¶ã¦ããè Öîú ‚ããõÀ ¾ãÖ ãä‡ãŠ ƒ¶ã‡ãñŠ ´ãÀã ã䪾ãñ Øㆠº¾ããõÀñ ½ãñÀñ ÔãÌããó¦¦ã½ã —ãã¶ã †Ìãâ ãäÌãÍÌããÔã ‡ãñŠ ‚ã¶ãìÔããÀ ÔãÖãè Öö /
Certified that I, have know Shri/Smt/Km......................... son/wife/daughter of shri................................ for the last................... 2
years........................... months and that to the best of my knowledge and belief the particulars by him/her are correct.

Ô©ãã¶ã/Place ÖÔ¦ããàãÀ/Signature..................................
ã䪶ããâ‡ãŠ/Date...................... ¹ãª ¾ãã ÖõãäÔã¾ã¦ã ‚ããõÀ ¹ã¦ãã / Designation or Status and address................................
 ‡ãŠã¾ããÃÊã¾ã ´ãÀã ¼ãÀã •ãã¶ãã Öõ / TO BE FILLED BY THE OFFICE

 ãä¶ã¾ãìãä‡ã‹¦ã ‡ãŠÀ¶ãñ ÌããÊãñ ¹ãÆããä£ã‡ãŠãÀãè ‡ãŠã ¶ãã½ã, ¹ãª¶ãã½ã ¦ã©ãã ¹ãîÀã ¹ã¦ãã / Name, desigantion and full address of the appointing authority.

 ¹ãª ãä•ãÔã‡ãñŠ ãäÊã¾ãñ ¹ãƦ¾ããÍããè ‡ãñŠ ¶ãã½ã ¹ãÀ ãäÌãÞããÀ ãä‡ãŠ¾ãã •ãã ÀÖã Öõ / Post for which the candidate is being considered.