Joining Check List For Staff Nurse Grade - II AIIMS, Kalyani

अखिल भारतीय आयुर्विज्ञान संस्थान (एम्स) कल्यानी
All India Institute of Medical Sciences (AIIMS) Kalyani

(स्िास््य एिं पररिार कल्याण मंत्रालय, भारत सरकार के तत्िािधान में एक सांखिखधकखनकाय)
(A Statutory Body under the Aegis of Ministry of Health and Family Welfare, GOI)
राष्ट्रीय राजमार्ग – 34, बसन्तपुर, सार्ूना, कल्याणी, ज़िला – नदिया, पज़िम बंर्ाल - 741245
NH-34 Connector, Basantapur, Saguna, Kalyani, District Nadia, West Bengal 741245
CHECK LIST
(for Joining as ……………………….….………….. in AIIMS, Kalyani
1. Acceptance for joining AIIMS, Kalyani.
2. Character Certificate (TwoGazetted Officer) in the prescribed format.
3. Allegiance to the Constitution in the prescribed format.
4. Oath of Secrecy in the prescribed format.
5. Declaration regarding Bigamous Marriage in the prescribed format.
6. Home Town Declaration in the prescribed format.
Declaration on Dependent Family Members in the prescribed format with age
7.
proof copy.
Declaration for OBC in the prescribed format alongwith valid OBC Certificate
8.
within six months.
Declaration for Spouse is employed in Government Services in the prescribed
9.
format.
Declaration of Marital Status from the new entrants to Govt. Service (alongwith
10.
marriage certificate if married).
11. Employee Data Sheet in the prescribed format.
12. Attestation Form in the prescribed format(Four copies duly filled and attested).
13. Declaration of Characters and Antecedents (in Rs.10/- Stamp Paper).
14. Undertaking for not tendering resignation within 6 months.
15. Form for New Pension Scheme(details to be furnished by the Govt. Servant).
16. Undertaking for submission of Factual Information in the prescribed format.

17. Medical Examination Report in the prescribed format.
18. Declaration of Immovable and Movable Property in the prescribed format.
Affidavit on non-judicial Stamp Paper mentioning that all your Educational
19.
Qualifications and Experiences are from recognised Institutes/College.
20. Discharge/Relieving Certificate from your previous employer.
21. Self-attested copies of all Educational(10th onwards)& Experiences Certificates.
Signature :…………………………..………………
Name :………………..………………………………
Date :………………..………………………………..
Dated :……/……/…………
To
The Executive Director,

AIIMS, Kalyani, West Bengal
Sub: Submission of acceptance for Joining in AIIMS Kalyani

as………………………………………………………..
Respected Sir,
With reference to your Offer of Appointment Letter

No.………………………. dated…………….., I hereby accept the Offer of
Appointment and all the terms & condition as contained therein. A set of self
attested certificates of my all qualifications and experiences are also enclosed.
I thank you once again for providing me the opportunity to serve the
Institute. I will join immediately as per the scheduled period given in Offer of
Appointment.
Yours sincerely,
Name : ………..………………..……………….
Designation : …………………………………..
Date of Birth :………..………………………...

CHARACTER CERTIFICATE
Certified that I have knownMr./Ms./……………………………………………………………………
Son/Daughter of Shri……………………………………………..…..……………………………… for
the last………….years ……………….months. He/She bears a good moral character and is of
………………………….nationality. He/She is not related to me.
Place: Signature :……………….………………..

Date : Name (in Capital Letters) :……………….………………..
Designation & Address :…………………………………
with Stamp
This certificate should be from any one of the following:
1. Gazetted Officer of Central or State Government;

2. Members of Parliament or State Legislature belonging to the constituency where the
candidate or his parent/guardian is ordinarily resident;
3. Sub-Divisional Magistrates/ Officers;
4. Tehsildars or Naib/ Deputy Tehsildars authorized to exercise magisterial powers;
5. Principal/Head Master of the recognized School/College/Institution where the candidate
studied last;
6. Block Development Officer;
7. Post Masters;
8. Panchayat Inspectors.
Allegiance to the Constitution
I ……………………………………………., do swear in the name of God/solemnly

affirm that I will bear true faith and allegiance to the Constitution of India as by law
established, that I will uphold the sovereignty and integrity of India, that I will duly and
faithfully and to the best of my ability, knowledge and judgment perform the duties of my
office without fear or favour, affection or ill-will and that I will uphold the Constitution and
the Laws.
Signature
Name : ….……………………………………………..
Designation : ………………………………………….
Department : ………………………………………….
FORM - I
OATH OF SECRECY
I, ………………………………………………………………(name)
do swear/solemnly affirm that I will be faithful and bear true allegiance
to India and to the Constitution of India as by law established, that I will
uphold the sovereignty and integrity of India, and that I will carry out
the duties of my office loyally, honestly, and with impartially. So “Help
me God”.
Signature : ……………………….
Name : ……………………………..
Signature of Head of Office

Dated :…………………..
Declaration Regarding Bigamous Marriage
I hereby declare that I have not entered into or contracted a

marriage with a person having a spouse living, or who, having a
spouse living, have not entered into or contracted a marriage with
me.
Signature :………………………………………..
Name : ….………………………..………………..
Designation :..……………….……………………
Department :..……………………………………..
HOME TOWN DECLARATION FORM

[ OM No. 43/15/57-Estts. (A) dated 24-6-1958]
I, ___________________________hereby declare that my home town is at the place as

shown below for the purpose of availing Leave Travel Concession for self and family as notified
in the Govt. of India, Ministry of Home Affairs, New Delhi O.M. No.43/1/55/Estts - (A) Part-II
dated 11-1-1956.
Home Town/Place Nearest Rly Station District/Town & Remarks

of visit State
_______________________
Signature
Name : ……………………………………………………………..
Designation : …………………………………………………….
Department : …………………………………………………….
Countersigned by ……………………………………………..
Head of Office
Date: …………………
Declaration on Dependent Family Members

(1) Personal Details:
1 Name
2. Designation
3. Date of Birth
4 Date of appointment
(2) Details of the Dependent Family Members:
Place mention
the category: Personal
Name(s) of the (a)Employed Annual
Date of Age as Marital
Sl. member(s) of Relationship (b)Pensioner Income of
birth on date Status
the family* (c) Family the
Pensioner dependent
(d)Others
(*) (i) I hereby undertake to keep the above particulars up-to-date by notifying to the
Head of Office of any addition or alteration.
(ii) Family for this purpose means family as defined in Clause (b) of sub-rule (14) of
Rule 54 of the CCS (Pension) Rules,
1972.[http://persmin.gov.in/pension/rules/pencomp7.htm#Family_Pension,_19
64]
(iii) Wife and husband shall include respectively judicially separated wife and
husband.
(iv) A self-certified proof of Date of Birth is enclosed in respect of dependent
Brothers/Sisters, if any.
Signature of the Employee
(Contd….P/2)
-:2:-
(3) For the use of Controlling Unit/Office of the HOD Forwarded
Forwarded Recommended
Section/Unit I/C HOD
(4) Administrative Approvals:
Checked Verified &Submitted for Approved as per

approval Rules
Dealing Assistant
Assistant Admin. Officer DD(A)/Director
To
The Executive Director,

AIIMS, Kalyani, West Bengal
DECLARATION
(OBC Candidates only)
I, ………………………………………………………………………………..…….
Son/Daughter of Shri……………..………………… resident of Village/Town/ City
……………………… District …………….…….…… State ………….………… hereby
declare that I belong to the …………………….community, which is recognized as a
Backward Class by the Government of India for the purpose of reservation in
services as per orders contained in Department of Personnel and Training Office
Memorandum No. 36012/22/93-Estt.(SCT), dated 08.09.1993. It is also declared
that I do not belong to persons/sections (Creamy Layer) mentioned in Column-3 of
the Schedule to the above-referred Office Memorandum, dated 08.09.1993. In
case, it is found at any stage that this declaration is incorrect, then my appointment
will be terminated without giving me any opportunity for representation.
Date:………………………………. Signature of the candidate
Name &Permanent Address
…………………………………..
…………………………………..
…………………………………..
…………………………………..
Note: To be filled only by OBC category

Date: ………………….
DECLARATION
(If Spouse is employed in Government Service)
I,……………………………………………………………………………….Son/Daughter of
Shri……………..…………………….………………resident of Village/Town/City
……………………District …………….…….…… State …………..……………………… hereby
declare that my spouse is employed/not employed in Government Service, and she/he is not
availing the following facilities for herself/himself or for any of the family members from the
Parent Department/Institute working for. I read the enclosed provisions made in the Government
Orders (printed overleaf) in this regard and undertake to inform the Institute as and when there
is any change in the status of employment of my spouse in respect of the following conditions.
1) Medical Attendance/Treatment
2) House Building Advance
3) Children‟s Educational Assistance
4) Family Planning Special Increment
5) Leave Travel Concession
6) Travelling Allowance
7) Family Pension
8) House Rent Allowance, if residing in Govt. Quarters
9) Central Government Health Scheme
10) Allotment of Residence
The relevant Rules as summarized in the enclosure (appended overleaf) are read and
certified that the same will be complied from time to time. I/we understand that any violation will
attract legal proceedings and penal provision as per Govt. Rules.
Signature of Spouse, Signature of

if employed Employee
elsewhere in Govt
establishments
Name : Name :
PF No. : PF No. :
Designation : Designation :
Department : Department :
Address : Address :
MARITAL DECLARATION
(To be obtained from new entrants to Government Service)
1. I, Shri/Smt./Kumari. __________________________ declare as under :-
(i) That I am unmarried/a widower/a widow.

(ii) That I am married and have only one spouse living.
(iii) That I have entered into or contracted a marriage with a person having a spouse
living. Application for grant of exemption is enclosed.
(iv) That I have entered into and contracted a marriage with another person during
the lifetime of my spouse. Application for grant of exemption is enclosed.
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
EMPLOYEE DATA SHEET Affix Stamp

Size
Photograph
1. Name in Full (First Surname)
2. Married Single Male Female
3. Mother’s Name (First Surname)
4. Father’s Name (First Surname)
5. (a) Present Address (for Communication) :
5. (b) Permanent Address :
Fax E-mail :
Telephone Office:
Residence: Mobile -
Day Month Year

6. Date of Birth
7. Nationality:
(Contd….P/2)
-:2:-
8. Category: SC ST OBC Gen
9. Academic Record starting with Secondary Education:

% of
Branch/ College/University
Examination Year Marks/ Division
Specialization /Institute
Grade
10. Professional Experience Record:

Name of Institution/
Position Held Date of Joining Date of Leaving
University
11. Please provide your family details (dependents only)

Present
S.No Name Date of Birth Relationship
occupation
DECLARATION
I, _____________________________________hereby, declare that all entries in

this form are true to the best of my knowledge and belief.
Date: Signature of the employee

ATTESTATION FORM
WARNING :- The furnishing of false information or suppression of factual information in the Attestation
Form would be a disqualification and is likely to render the candidate unfit for employment under the
Government.
2. If detailed, convicted, debarred etc. subsequent to the completion and submission of this Form
the details should be communicated immediately to the Ministry of Health & Family Welfare,
Government of India, New Delhi 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 a suppression of factual information.
3. If the fact that false information has been furnished or that there has been suppression of any
factual information on the attestation form comes to notice at any time during the service of a person,
his/her service would be liable to be terminated.
(i) Name in full (in block capitals) with address, SURNAME NAME
if any, please indicate if you have added or
dropped in any stage any part of your name
or surname.
(ii) Present address, in full (i.e. Village, Thana &
District or House No., Lane, Street, Road &
Town)
(iii) (a) Home Address in Full (i.e. Village, Thana
& District or House No., Lane, Street, Road
Town & name of the District Headquarters.)
(b) If originally a resident of Pakistan the
address in the country and the date of
Migration to Union of India.
4. Particulars of places (with period of residents) where you have resided over 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.
From To Residential address in full (i.e. Village, Name of the District
Thana & District or House No., Lane, Headquarters of the place
Street, Road & Town) mentioned in the
preceding Column
-:2:-
Occupation if
Nationality employed Present Postal
Name in Full (by birth Place of give Permanent Home
5 (a) Address if dead give a
(Aliases, if any) and/or by Birth designation & Address
last address
domicile) official
address
(i) Father
(ii) Mother
(iii) Wife/Husband
(iv) Brothers
(v) Brothers
(vi) Sisters
(vii) Sisters
5. (a) Information to be furnished with regard to son(s) and/or daughter(s) in case they are studying/living in a Foreign Country.
Date from which
Nationality (By Place of Country in which studying with studying/living in the
Name
Birth/domicile) Birth full address country mentioned in
previous column
(Contd……P/3
)
-:3:-
6. Nationality of the candidates :
7. (a) Date of Birth :

(b) Present Age :
(c) Age at Matriculation :
8. (a) Place of Birth, District and :

State in which situated
(b) District and State to which :
you belong.
(c) District & State to which
your father originally belong :
9. (a) Your Religion :

(b) Are you a member of a Scheduled
Caste/Scheduled Tribe/OBC
(Please indicate)
10. Educational Qualification showing Places of Education with years in Schools &
Colleges since 15 years of age :
Date of Date of Examination

Name of the School/College with full address
Entering Leaving Passed
(Contd……P/4
)
-:4:-
11. (a) Are you holding or have any time hold an appointment under the Central Govt. or State
Govt. or a Semi Govt. or a Quasi Govt. Body or an Autonomous Body or a Public
Undertaking with date of employment uptodate :
Period Designation,
Emoluments & Full name & address of Reasons for leaving
From To nature of employers previous service
employment
11. (b) If the previous employment was under Govt. of India, a State Govt.,an Under-taking
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 Service (Temporary service) Rules, 1965 or any similarly
corresponding rules were and disciplinary proceedings framed against you or had you
been called up to explain conduct in any matter at the time you gave notice of
termination of service, or at subsequent date, before your service actually terminated?
12.(1)(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 bound down? Yes/No
(e) Have you ever been fined by a Court of Law? Yes/No
(f) Have you ever been convicted by a Court of Law for any offence? Yes/No
Have you ever been debarred form any Examination or restricted
(g) Yes/No
by any University of any other Educational Authority/Institution.
Have you ever been debarred/disqualified by any Public Service
(h) Yes/No
Commission for any of its Examinations/ Selections?
Is any case pending against you in any Court of Law at the time of
(i) Yes/No
filling up this Attestation Form?
Is any case pending against you in any University or any other
(j) Educational Authority/Institution at the time of filling up this Yes/No
Attestation Form?
(Contd……P/5
)
-:5:-
12. (2) If the answer to any of the above-mentioned questions is ‘yes’ give full particulars of the
case/arrest/detention/time/conviction/statement/punishment etc. and or the nature
of the case pending in the Court/University/Educational Authority etc. at the time to
filling up this 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 by striking out ‘YES’ or ‘NO’ as the
case may be.
13. Name of the two responsible persons at your 1.

locality or two residents to whom you are
known
2.
I certify that the foregoing information is correct and complete to the best of my
knowledge and believe. I am not aware of any circumstances which might impair any fitness for
employment under Government.
Place:
Date: Signature of the Candidate
DECLARATION FOR CHARACTERS AND ANTECEDENTS

(It should be typed & singed by the candidate in a Rs. 10/- stamp paper)
I, Ms/Mr………………………………………………….Son/Daughter/Husband/Wife
of…………………………………………………..………………………….presently resident
at ……………………………………..…………………….……………………………. declared
as under :-
1. I have not ever been arrested.

2. I have not ever been prosecuted.
3. I have not ever been kept under detention
4. I have not ever been bound down.
5. I have not ever been fined by a Court of Law.
6. I have not ever been convicted by a Court of Law for any offence.
7. I have not ever been debarred from any Examination or restricted by any University
or any other Education Authority/Institution.
8. I have not ever been debarred/disqualified by any Public Service Commission or
Recruitment or any other Examinations/Selection.
9. No case is pending against me in any Court of Law as on date.
10. No case pending against me in any University or any other Educational
Authority/Institution as on date.
11. I have never been discharge/withdrawn from any Training Institution under the Govt.
or otherwise.
Based on the above declaration, I may kindly be issued provisional appointment

order which is pending for verification of character antecedent from the appropriate
authority.
I hereby undertake that in case of anything adverse is found in contradiction to

the above declaration the provisional Offer of appointment may be cancelled without
giving further opportunity.
Date: ………………………………… Signature of the candidate
Name :
Permanent address :…………….

……………………...……………..
……………………………………..
……………………………………..
……………………………………..
UNDERTAKING FOR NOT TENDERING RESIGNATION WITHIN 6 MONTHS
I,……………………………………………………………………….Son/
Daughter of Shri…………….…………..………………resident of
Village/Town/City…..……………………District …………….…….…… State
…………..……………………… is hereby undertake that I will not tendermy
resignation from the present post within 6 months after joining as
………………………………………………………………..……….(post) in
AIIMS Kalyani, West Bengal.
Signature with Date
Name :………………………………………………
Annexure-I
New Pension Scheme

(Details to be furnished by the Government servant)
Name of the Government servant (in Block Letters) :
Designation :
Name of Ministry/Deptt./Organization :
Scale of Pay :
Date of Birth :
Date of joining Government service :
Basic Pay :
Nominee for accumulations the Pension Account :
Relationship
Percentage of
Sl. Age Date of with the
Name of nominee(s) share of
No. Birth Government
payable
servant
(1) (2) (3) (4) (5)
Signature of the Government servant

UNDERTAKING
(For submission of Factual Information)
1. The furnishing of the false information or suppression of factual

information on my joining would be a disqualification and will
render my appointment to be cancelled at any stage.
2. If it has been found that I have furnished false information or that

there has been suppression of any factual informationwhich come
to the notice at any time during my service, my service will be
liable to be terminated.
3. The Degree/Diploma and Experience Certificates as declared by

me in on-line applications are recognised by the University/other
Government regulating agencies. In case, it is found that the
same is not recognised by at any stage, my appointment may be
cancelled.
4. I also declare that I possess all requisite qualification and

experiences as per the requirement of the advertisement and in
case it is found that I am not fulfilling any eligibility criteria, then
my appointment will be treated as cancelled.
Signature with Date
Name :………………………………..…
MEDICAL FITNESS CERTIFICATE
I hereby certify that I have examined Mr./Ms………………………….........…….. a candidate

for employment in the All India Institute of Medical Sciences(AIIMS) and cannot discover
that he/she ………………………………………………..………..(name of the candidate) has
any disease (communicable or otherwise), constitutional weakness or bodily infirmity
except ………………………………………………………………………………... I do not consider
this a disqualification for employment in the Office of All India Institute of Medical
Sciences (AIIMS).
Signature/Thumb and finger

impressions of the Candidate
Place :
Date : Civil Surgeon/District Medical Officer/
Medical Officer of equivalent status
CANDIDATE’S STATEMENT AND DECLARATION
The candidate must make the statement required below prior to his medical examination
and must sign the declaration appended thereto. His attention is specially directed to the
warning contained in the Note below:-
1. State your name in full (in block letters) ………………………..……………………………….
2. State your age and place birth ……….……………………………….…………………………...
3. (a) Have you ever had smallpox, Intermittent

or any other fever, enlargement or suppuration
of glands, Spitting of blood, Asthma, heart disease
Lung disease, fainting attack 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? ……….…………………………….………………
(Contd.….P/2)
-:2:-
8. Furnish the following particulars concerning your family:
Father’s age if Father’s age at No. of brothers No. of brothers dead,

living and state of death living, their ages at death and
health. and cause of their ages and state cause of death.
death. of health
1.
2.
3.
Mother’s age if Mother’s age at No. of sisters living, No. of sisters dead, their
living and state death and cause their ages and state ages at death and cause
of health. of death. of health. of death.
1.
2.
3.
I declare all the above answers to be, to the best of my belief, true and correct.
I also solemnly affirm that I have not received disability certificate/pension on account of
any disease or other condition.
Date : Signature/thumb and finger

impressions of the candidate
Signed in my presence: …………………………..

Signature of Medical Officer/District Medical
Officer /Medical Officer of equivalent status
N.B : the candidates shall be held responsible for the accuracy of the above statement.
By wilfully suppressing any information he will incur the risk of losing the appointment
and, if appointed, of forfeiting all claim to superannuation allowance or gratuity.
[M.H. OM No. F.5 (11)-55 MII dated the 27th September, 1957]
Important Note: B(2)(b): In the case of female candidate appointed to a non-gazetted

post (i) in Delhi the medical certificate shall be signed by an Assistant Surgeon Grade-I
(Woman) under the Contributory Health Service Scheme; and (ii) in any other place by a
registered female medical practitioner possessing a medical qualification included in one
of the schedules to the Indian Medical Council Act, 1956 (102 of 1956) (Indian Medical
Central Act, 1970 and Homoeopathy Central Council Act, 1973).
RULE 18. MOVABLE, IMMOVABLE AND VALUABLE PROPERTY:
THE SCHEDULE
[See Rule 18 (1)]
Return of Assets and Liabilities on First Appointment on the _____________, 20 .
1.Name of the Government servant in full……………………………………………………………………………………….

(in block letters)
2. Service to which he belongs…………………………………………….
3. Total length of service upto date……………………………………….
(i)in non-gazetted rank.

(ii) ingazetted rank.
4. Present post held and place of posting…………………………….
5. Total annual income from all sources during the Calendar year immediately preceding the 1st day of January 20 .
6. Declaration -
I hereby declare that the return enclosed namely, Forms I to V are complete, true and correct as on…………….to the
best of my knowledge and belief, in respect of information due to be furnished by me under the provisions of sub-rule
(1) of rule 18 of the Central Services (Conduct) Rules, 1964.
Date………………….
Signature………………………….
Note-1 : This return shall contain particulars of all assets and liabilities of the Government servant either in his own
name or in the name of any other person.
Note-2 : If a Government servant is a member of Hindu Undivided Family with coparcenaries rights in the properties
of the family either as a „Karta‟ or as a member, he should indicate in the return in Form No. I the value of
his share in such property and where it is not possible to indicate the exact value of such share, its
approximate value. Suitable explanatory notes may be added wherever necessary.
FORM NO. I
Statement of immovable property on first appointment as on the ____________, 20 .

(e.g. Lands, House, Shops, Other Buildings, etc.)
Sl. No. Description of Precise location Area of land (in Nature of land in Extent of If not in own
property (Name of District, case of land and case of landed interest name, state in
Division, Taluk and buildings) property whose name
Village in which the held and his/her
property is situated relationship, if
and also its any to the
distinctive number, Government
etc.) servant
1 2 3 4 5 6 7
Date of How acquired Value of the Particulars of Total annual Remarks

acquisition (whether by purchase, property (see Note sanction of income from the
mortgage, lease 2 below prescribed property
inheritance, gift or authority if any
otherwise) and name
with details of
person/persons from
whom acquired
(address and
connection of the
Government servant, if
any, with the
person/persons
concerned) Please
see Note 1 below)
8 9 10 11 12 13
Date …………………….
Signature ……………………………….………….
Note (1) For purpose of Column 9, the term “lease” would mean a lease of immovable property from year to year or
for any term exceeding one year or reserving a yearly rent. Where, however, the lease of immovable property is
obtained from a person having official dealings with the Government servant, such a lease should be shown in this
Column irrespective of the term of the lease, whether it is short term or long term, and the periodicity of the payment
of rent.
Note (2) In Column 10 should be shown -
(a) where the property has been acquired by purchase, mortgage or lease, the price or premium paid for such
acquisition;
(b) where it has been acquired by lease, the total annual rent thereof also; and
(c) where the acquisition is by inheritance, gift or exchange, the approximate value of the property so acquired.
FORM NO. II
Statement of liquid assets on first appointment as on the __________________, 20 .
(1) Cash and Bank balance exceeding 3 months‟ emoluments.
(2) Deposits, loans, advances and investments (such as shares, securities, debentures, etc.)
Sl. No. Description Name & Amount If not in own Annual income Remarks
Address of name, name derived
Company, Bank and address of
etc. person in whose
name held and
his/her
relationship with
the Government
servant
1 2 3 4 5 6 7
Date …………………….
Signature ………………………….
Note 1. In column 7, particulars regarding sanctions obtained or report made in respect of the various transactions
may be given.
Note 2. The term “emoluments” means the pay and allowances received by the Government servant.
FORM NO. III
Statement of movable property on first appointment as on the ________________, 20 .
Sl. No. Description of Price or value at If not in own name, How acquired with Remarks
items the time of name and address approximate date
acquisition and/or of the person in of acquisition
the total payments whose name and
made upto the date his/her relationship
of return, as the with the
case may be, in Government
case of articles servant
purchased on hire
purchase or
instalment basis
1 2 3 4 5 6
Date ………………….
Signature …………………….……………….
Note 1. In this Form information may be given regarding items like (a) jewellery owned by him (total value); (b) silver
and other precious metals and precious stones owned by him not forming part of jewellery (total value), (c) (i) Motor
Cars (ii) Scooters/Motor Cycles; (iii) refrigerators/air-conditioners, (iv) radios/radiograms/television sets and any other
articles, the value of which individually exceeds Rs. 1,000 (d) value of items of movable property individually worth
less than Rs. 1,000 other than articles of daily use such as cloths, utensils, books, crockery, etc., added together as
lump sum.
Note 2: In column 5, may be indicated whether the property was acquired by purchase, inheritance, gift or otherwise.
Note 3: In column 6, particulars regarding sanction obtained or report made in respect of various transactions may be
given.
FORM NO. IV
Statement of Provident Fund and Life Insurance Policy on First Appointment as on the ______________,
20 .
Sl. Policy No. Name of Sum Amount of Type of Closing Contribution Total Remarks (if there
No. and date of Insurance insured annual Provident balance as made is dispute
policy Company date of premium Funds / last subsequently regarding closing
maturity GPF / CPF, reported balance the
(Insurance by the figures according
Policies) Audit / to the
account No. Accounts Government
Officer servant should
along with also be
date of mentioned in this
such column)
balance
1 2 3 4 5 6 7 8 9 10
Date ………………….
Signature …………………………………..…………….
FORM NO. V
Statement of Debts and Other Liabilities on First Appointment as on _____________, 20
Sl. No. Amount Name and address of Date of incurring Details of Transaction Remarks
Creditor Liability
1 2 3 4 5 6
Date …………………….
Signature ……………………….……………….
Note-1 : Individual items of loans not exceeding three months emoluments or Rs. 1,000 whichever is less, need not
be included.
Note-2 : In column 6, information regarding permission, if any, obtained from or report made to the competent
authority may also be given.
Note-3 : The term “emoluments” means pay and allowances received by the Government servant.
Note-4 : The statement should also include various loans and advances available to Government servants like
advance for purchase of conveyance, house building advance, etc. (other than advances of pay and
travelling allowance), advance from the GP Fund and loans on Life Insurance Policies and fixed deposits.
Before the Notary Public, ………………………………………….
AFFIDAVIT
I Dr._____________________aged about ______ years, Son of ____________
_________________ Resident of ____________________, do hereby solemnly affirm

and state as under:-
1. That I am the deponent of this affidavit.
2. That I do hereby declare that I am not indulged or doing private practice of any
kind including laboratory and consultant practice.
3. That presently I am not working at any other Institutions or Medical College or

Government/Autonomous/Semi Government Organisation. I have been relieved
by the Institution where I was working previously before joining AIIMS,Kalyani.
4. That I have passed MBBS in the year _______ and MD in the year ______.
5. That I am not drawing any salary/pension from any source other than AIIMS,
Kalyani.
6. That this affidavit is required to be produced before the Director, AIIMS, Kalyani
for necessary action.
7. That all educational qualifications and teaching/research experiences are from

MCI recognized Institutes/College.
That the facts stated above are true to the best of knowledge and belief.
Deponent Deponent
Notary Public

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अखिल भारतीय आयुर्विज्ञान संस्थान (एम्स) कल्यानी

All India Institute of Medical Sciences (AIIMS) Kalyani

13. Declaration of Characters and Antecedents (in Rs.10/- Stamp Paper).

14. Undertaking for not tendering resignation within 6 months.

16. Undertaking for submission of Factual Information in the prescribed format.

The Executive Director,

Sub: Submission of acceptance for Joining in AIIMS Kalyani

With reference to your Offer of Appointment Letter

Date of Birth :………..………………………...

Certified that I have knownMr./Ms./……………………………………………………………………

Son/Daughter of Shri……………………………………………..…..……………………………… for

the last………….years ……………….months. He/She bears a good moral character and is of

………………………….nationality. He/She is not related to me.

Place: Signature :……………….………………..

This certificate should be from any one of the following:

1. Gazetted Officer of Central or State Government;

Allegiance to the Constitution

I ……………………………………………., do swear in the name of God/solemnly

Signature of Head of Office

Declaration Regarding Bigamous Marriage

I hereby declare that I have not entered into or contracted a

HOME TOWN DECLARATION FORM

I, ___________________________hereby declare that my home town is at the place as

Home Town/Place Nearest Rly Station District/Town & Remarks

Declaration on Dependent Family Members

Signature of the Employee

(3) For the use of Controlling Unit/Office of the HOD Forwarded

Section/Unit I/C HOD

(4) Administrative Approvals:

Checked Verified &Submitted for Approved as per

The Executive Director,

Date:………………………………. Signature of the candidate

Name &Permanent Address

Note: To be filled only by OBC category

Signature of Spouse, Signature of

1. I, Shri/Smt./Kumari. __________________________ declare as under :-

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

EMPLOYEE DATA SHEET Affix Stamp

1. Name in Full (First Surname)

2. Married Single Male Female

3. Mother’s Name (First Surname)

4. Father’s Name (First Surname)

5. (a) Present Address (for Communication) :

5. (b) Permanent Address :

Day Month Year

8. Category: SC ST OBC Gen

9. Academic Record starting with Secondary Education:

10. Professional Experience Record:

11. Please provide your family details (dependents only)

I, _____________________________________hereby, declare that all entries in

Date: Signature of the employee

6. Nationality of the candidates :

7. (a) Date of Birth :

8. (a) Place of Birth, District and :

9. (a) Your Religion :

Date of Date of Examination

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

13. Name of the two responsible persons at your 1.

DECLARATION FOR CHARACTERS AND ANTECEDENTS

I Dr._______aged about years, Son of

_ Resident of ____, do hereby solemnly affirm