1

SPECIAL SECU RITY QUESTIONNAIRE

(To be adopted for re-verification)

Name:

Appointment held

Office: Passport
(Complete official address)
size

photograph

1. Candidates should ensure that the information required against each

heading is fully and correcly
given.

2. lf it comes to the notice at any time subsequently that false information

has been furnished or thal.
there has been a suppression of factual information in this form, his
services will be liable to be
terminated solely on this ground.

Surname Forename
3. (a) Name in full

(b) Aliases (if any)

(c) Name at birth, if different and any other names,

surnames used at any stage.

4. Address:

(i) Present Address:

(a) House No./Name

(b) Locality/Street

(c) Town/Village

(d) Police Station

(e) Post Office

(f) District

(g) State

(h) Pin code

 (ii) Permanent t-iome address:

(a) House No. /Name

(b) Locality/Street

(c) Town/Village
(d) Police Station

(e) Post Office

(f) District

(g) State

(h) Pin Code

(iii) lf originally a resident of a country other than lndia:

(1) Address in the foreign country:

(a) Name of country: (e) police Station:

' (b) House No./Name: (f) post Office:
(c) Locality/Street: (g) District:
(d) TownA/ittage etc.:
(2) Date of entry to lndia:

(3) Check post or point of entry:

(4) Particulars of travel documents:

5. Phone/Mobile number(s) registered in the name of candidate and used by him:

6. E-mail lD for communication:

T. *"n no of ;.r.";; ,", . ,r" ,ur; o,,n"'"r., orr" ,"0 ,r"o

",rr,." ",., " by him:
 3

10 Personal Passport No.

Validity upto

11 . (a) Date of birth: (b) Place of birth:

(c) District: (d) State:

(d) Country:

12. (a) Nationality-

(b) Religion-
13. (a) Particulars of places (with periods of residence) where you have resided for more than one
year at a time during the preceding three years:

From To Full address including Village, Police Station, Post Office, Town,
House & Street Number, etc.

(b) lf you have stayed abroad, give particulars of all places where you have resided for more
than one ear after attaininq the sge of 1B (Eiqhteen) vears:-
From To Full particulars including Village, Reasons for
Police Station, District, Towfl, House visit/residence
and Street Number, Name of the
Qqulry e_!c.

14. Have you ever had personal contact with an official of a

Foreign country other than as a result of official duties?
lf yes, give details.
 4

15. i) If applicable, please give full name, date, place of

birth and occupation of spouse(inctuding de facto spouse).

ii)Has this person (spouse) visited or resided in any overseas

country or are his or her relatives residing overseas'/
lf yes, please give details.

16. (i) Have you any other person over 1B years residing with you?
lf yes, please give details, regarding name in full, date
and place of birth, relationship and occupation.

(ii) Has any person over 1B years residing with you, visited
or resided in overseas countries? lf yes, please give detaits.

17. Give detaits, if you have ever been:

(a) Arrested

(b) Prosecuted

(c) Kept under detention

(d) Charged before a Court with an offence for which you were
convicted, conditionally discharged, placed on probation or
bound over or acquitted?

(e) Debarred or disqualified by any Public Service Cornmission

for any of its examinations/selections?

(f) Debarred from taking any examination or rusticated by any University?

(g) Discharged or dismissed from any employment?

(h) Whether discharged/expelled/withdrawn from any training
institution under the Government or otherwise?

18. Has any criminal case been registered against

you in which you may/may not have been arrested,
charge sheeted or detained?

19. ls any case or enquiry pending against you in any

Court of Law (including Civil Litigation) or any other
authority e.g. departmental proceedings etc.?

20- Have you ever been a prisoner of war or held in enemy

country for any duration? lf so, give details.

21. Are you an arms licence holder? lf so, give details of

licence and arms in possession.
 22(a). Particulars of close relatives.
- - -P[ace/ - ___-iiAseni
--
Name fiEiionatitv Occupation (if Perma#ni
(by birth or Country employed give Postal Home address
by domicile) and date designation add ress (if
of birth and official dead give
address) last home
address

(a) Father

(U ffithe;

(c) Wifel
H usband

(d ) Son(s)

G)D*sht r(r)

(f) Brother(s)

(g) Sister(s)

irilst"p:So;as)

(i)Step-
Daughter(s)
 (b). Pafiiculars of in-laws (if appticable):

- -pttce/
rrtitio*iity I occup'atron |if - PrAseni* -- Ceim;nent
*
(by birth or I Country ernployed give Postal Horn e address
by domicile) | and date designation address (if
of birth and official , dead give
address ) last home
aqqr_e_ssI___
(a) Father-in-
:a--__--_]l1]_-_---___ 0__
Law

(b) Mother-in-
law

(c) Brother(s)-
in-law

(d) Sister(s)-
in-law
 7

23. (i) Particulars of relatives (lndian and Non-lndian) working in (a) Foreign Missions and (b)
fqlgl_g_l O rg ? n izat o n s i n cl Ud n gjorei_g! gglfqgln :I
i i

Name(s) Nationality Occupation ( (if Present Permanent

employed, g ive Residential address
designation and address
I I e!fi_c1ql_e!9rese)__

(ii) Do you have any relatives (including children) living overseas? lf yes, please give the
followinq details of each one:-
Name(s) in full Relationship eountry of re$dence Date(s)

24. (a) Have.yo, been a member of any cultural or social

organization which is associated with or assisted by YeslNo
foreign Mission or organization?

(b) Are you aware whether any of your relatives mentioned

in column No. 22 has been a member of any cultural or Yes/No
social organization which is associated with or assisted
by a Foreign Mission or Organization?

(c) Are you or have been a member of any Club/Society and/or

other such bodies? Yes/No

lf the answer to (a), (b) and (c) or any of them is 'yES' give foilowing details:

(a) Name of the Organization/Club/Society etc.

(b) Name of the office Bearers

(c) Period of membership

 8

(d) Details of any post/office held

(e) Whether still active or not?

(f) Reasons for relinquishing membership '

(g) Any other relevant details

25.(a) Have you ever been a member/worker of any political party/ Yes/No
organization or participated in any political activities?

(b) Are you aware if any of your relatives mentioned in column Yes/No
No. 22 has ever been or continues to be a member/worker of any
political party/organization or ever participated in any
political activity?

lf the answer to (a) and/or is 'YES' give the followin details:

Particulars Name of Particulars Period of Nature of Particulars
of relatives Political Pa rtyl of political membership of participation of office if
(name/ Organization activity. political in political any, held in
relation ) party/org. or activity political
participation in party.
political
activitL--_

(c) Have your or any of your relative mentioned in column No. 22 been a member/worker
of any Social/Political/Religious/Service Orgn../Union/Club?
lf so, details thereof mav be qiven below:
Orqanization Place Year Status

26. Have you or your wife any debts or outstanding loans?

lf so, give details.

Note: (1) Acceptance of purely temporary loan of small amount free

of interest from a relative or personal friend, or operating
a credit account with a bonafide tradesman shall not be
treated as debt/loan under this column.
 (2) No details will be necessary in respect of any loan obtained
with the previous sanction of the Government.

27. State source of your income and that of the members of your family,
giving all details.

28. Mention details of movable/immovable property including agricultural

land etc. in your wife's/husband's name.

29. I have read and understood the Provisions of Paras 1 and 2.

30. 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 Governrnent.

(Signature of the candidate) *.

Place.

Date
 G
---.:.-..-..5

ti:

q(Tl"qq gq,
ATTESTATION FORM

*,rerfr
WARNINC
rrsqtC oTrfiR (o.rw 5 r)f, x
I. Effi T{rTIW q-rDr fr r"ra T{.ff]T qffiT 3Talil EKflfuzF duT gqlq
qTi t +fr ) qff q6 Grntrr=T
rbi s{ril-'q-f,r qrqT "ileTT f,eIT 6-q1sp oTHT?fi o} TJTfiIfi ffi d I?N E-{flTeTR-f, qH q-fr qgt
qlR-n fuql qT $mq B r
frrumx I

"1og*
"l'he lurnishing of false infbrmation or suppression of any factual
lnfbrmation irr the Attestation folnr woulcl be a disqualification, and is Affix signed passport size
likely to rencler tlre candidate unfit for employntent under the Govetnment. (5 CM x 7 CM approx) copy of
recent photograph.

qft gs qq, fuI wi d qr< er.qeff o} e-qrd-rd ii sren'rqr d, ft{q-flR ft;qrrql. e\, ss gt\
q{r 6-{i q s-*gd ql
2. aD)
g.=qr;-* ,"id, vs q{ dtrfls d.nqr TsT E\. s-s s{ frti qMq"r fr-'qrqrq; E\' qBqf, frrqr rrqr r\ 3prfl
{1q3 ffi 31.'6 fu+r .rqr e\ o\ g*r elrvrq q,1 t{IqT iFqa gct 3ffDr6.rft th) ffi fu-+ T6 T{czrlrrq erre +qt rt-qr
B r ful c fuq qri qq qE cmr qn'q.r fu
q"sPff srrflfutr f,24 gqT rsr t I

and sub-
Ifdetained, arrested, prosecuted, bound down, fined, convicted, debarrcd, acquitted, etc. subsequent to the contpletion
to the authorities to whom the attestation form has beerr sent
mission of this form, the details should be communicated imrnediately
early, failing which it will be deemed to be a suppression of factual inforrnation.

3. qR afur S d--rg far{ff fi T{q"rr z16 qcr1 ??rdT t fu s{ri lrtzlrrq qq, q znr{'r-ea qm rfr t
zhl tfsT elsrfl
Emf,fr-o aedi a;\ gqrql t, d s-e-ot iW eqrrd o1 rnr rro-ft d t

iD the Attestation tbrnt

lf tlre fact that false iliformation has been furnished or that there has been suppression of any faclual infolmation
.or.rl?o notice at any time during the service of a pel'son, his selviees rvould be liable to be TERMINATED'

1. g.Filq\ Hftn, ?TR ,Ft{ E\ T{T qrq Ffa qn ri m?fr 3{q-.i RITI %,OTIq
3[e;cll, BE-iTq q erqff,: Eu .ftgr .iTe{ql funfen d ni \rS SURNAME
frftHE 6t) I

qrIT
Name in full (in BLOCK CAPITAL.S) with aliases, if any. (Please indicate
you have added or dropped in any stage any paft of your name ol' sul'name) NAME

2. qdq6 WT rfflT gT?f1q.ffE, elfqT dqT fu-mT 3TelciT qc51q n.,'T Ofrl
{*e /wso f,zTI Yr6-{

Present Address in full (i.e., Village., Thana and District, ol'Hotlse Nutr-
ber, L,ane/Street/Road and Town.

(o) qr q-fir;l n., T -fr t

T{l rtrlT (sTrth .nq, er,il dall fu--frT sTzrqT
..'
J. Err
rfic /wvw q elw) Gil-{ fikqT 5!ETrG-q c-T qrrT
(a) full (i.e,, Village, Thana altd District ol'House Nunt-
Horne Address in
ber'. Lane/Street/Road and Torvn and nanre of District Headquallel's.

(qs) qR {fr-n: qlfrt{nTE / qrrrl iYT (S Yfl qrfrt{n-q 61 frrqxft t dr

ss t?T t'q6-i fr-T qf,T dzTT IIFI t -Trrf, sTri q,1 drfrtrr
g-".*&-{q ?FT

.n{) r

(b) lf originallv a resident of Pakistan/Bangladesh (erst-rvhile East Pakis-

tan tlie add;ess in that courptr'1, aird the ciate ol'nrigratiorl to Indiall Uttion.)
 f
4' rrf, crq Ed d. <trn sq wFi q) d.t (en+r:o-or-+ls t *8, enqi ro rrrq d g'-fi qs t eiB@ 3r-qD d ftq
ftq,'ir fu*. slt rr q{ d't 3flq Hrci m-{i'd ,ft *. **i'rrfuo
F-qrn ft-,qr E\ o) sc v+.fi s€n+ d .ff
-'"tro) *R' .* t=t t q- #'fi -C, d ft!
*g" dt
Particulars of places (with periods of residences) wheie you
#l-
have resided for more ihan one year^al atime during
the preceding five
Pakistan) particuiars orall places where
ilt3:t;.';,.fi$::?r33ffi11til,1|ot'* vou have resided for mor.e ,r,u" attalning
"r.-y"r'.fler

\1 cicD Er q-o, (3rrrfq, rn+, enqT ti

"rT TET Xd ef_.{q sffio
1qlq ;;
deIT rg-dr 3TarqFrorq =i. .rfr l€u I frrer 3u<rau o-r qFr
l]--sfr oQlT eTEg

From To Village,
Residential address in full (i.e. Name of the District Headquarters of
Thana and Dist. or House No. l,anel the place mentioned in the preceding
Street/Road and Town) column.
t ----- *;- *--;-**--
2

5. qlq {Hlq-f,r (q-.q q;q qir{]rq (qR

{alFI q-el.ilt 6-r . q{ zF-l {a11-$
ofr{ / s,prq ii-qn-a d dr qdqlq qdT qflI
sr[*-qTu gm) q{qiEi q orc- Eti et
(ft-qrrn
ft-r qET ffi) frqfr q erfrq
qaT)

Name Nationality (by Place of birth Occupation (if Present Postal Permanent ljome
Binh andlor by employed give address ( i1- dead Address
domicile) designation and give last address)
Official address)

I
t+i J
6

(o) fr-ci Fq-nqr qrB-n qR .d{ O

(a) F ather (Name in full aliases. if any).
(ru) qrn
(b) Mother

(.i) q-ifr/qfr
(c) Wifc/l{usband

(q) .rTs
(d) Brother( s)

(s) qE{/q-6-i
(e) Sister'(s.;
 5. (o) w y/V\ oflr g*7gBdr d qTt t vBri u) tud?T fr t q-o G/ra v3 t,-
(a) Infolmarion to be fiititishr:d rvith regard to solr(s) and/or, daughter(s) in
case they are studying/living in a FOREICiN COUNTI{y:-

qlq SHFTmT (u=n w;EI WdI;i t

fuq1 tYT S m-I-dq q sfttrfur
Gfu / a+srqr w€/w€ t"T fr rne t q6 €/
orfBqrn ETrT) t, tsT{cfl WT Kn 16€d
Name Nationality (by birrh Place of birth Country in r,vhich Date fi'orn ,uvlrich
" and/or by donricile) studyinglliving in
studyin !living ra,ith
full address the cou ntry men-
tioned in previous
column

6. qI*?lnT
NATIOANLITY

7 (o) tr;q frfu . (o)

(a) Date of birth (a)

(ir) qdqre oTrg (qs)

(b) Present Age (b)

(,i) +f,ednr d q-$rrrr-cre t f,r ,r( orrg ('T)

(c) Age at Matriculation (c)

8. - - -- -----'---------
(o) fta-d u *r*'"r-*,
"c"
(a) Place of bifth, District arrd
r= *","
State in which situated
a;l------'-'-'--'-i
(a)

(u) om frrfl ffi zr rluzt r\ rnrq€ d i (s)

(b) District and State to r.vhich you belong (b)

(.r) srqri ft-oi Ta-o, fr-€' ftild q rlvir rrqq dt r (,T)

(c) Distlict and State to rvhiclr 1,our father originally belong (c)

9. (m) oTrmr rd
(a) \'our religion

(qs) qqT 3ilrl rnrfo Er orgEpa .f,-rrf,rfr/

rrq ffi wft t q]rq€ d? fiiii* qrrqG C, sfi-qr-T
nH frrrq r

(h,) At'e you a nterrrber uf Sclreduled Caste/Ssheduled 'I'r'itre/OBCI?

Il'ansu'er is 'Yes'. state tire nan're tlrert:of.
 :i
r0. 15 s{ of 3TE Q fu{
r+..dr s fr Rren qla qi t, flrers rlfta $r-<Dr
o1ffi sds
6{fr gv r}eiFim qf.Tf,r ftrci I

Educalional qualificatic,n showing places of educalion with years in Schcols an<! Colleges since l5lh year of ags.

Ti.rd irRa l:s^drlmTffi

d qpr
rqm/mTfu-q fr rw/oifrr'n ffi ihl-{ {fr .rftHT
q-AYT frt nrfr'{s Ebt rTrft'{s qI{{ a1

Name of School/Colleges with Date of entering Date of leaving Examination passed

Full address

, Bqlnc aTern m q-{ orercT $sarrq n t-ff-d d ersrq-r i}Trrd ro gd qfr t?

it-sT o1 dd drffi
v+trir Wf
eil-ekrq d-{ t r

(A) Are you holding or have any time held an appointment under the Central or State Government or a Semi-Government or a
euasi-
, Government body, or an autonomous body, or a Public Undertaking or a Private Firm or Institrrtion? If so, give full particrrlars
with dates of employment, upto date.

orqftsr q{qrsI, tf,E f,QTT t{qT fudrffir en-r T{T W+dT

PE.RIOD rht n{ft qTrI q qcll EH d En-rror
t Tff Desi gnati on, emol untents Full name & address of Reasons for leaving
FROM TO & nature of employment employer' previous service

ll. (s) qil fru*i) tJ-qT qrrf, Tflqbr(, rrcq rflqlrclfrr!fr

gqrF-q ?i, q"iTB-fqTtfi-{ 3Tq cIT ?lT{d r1{fi-rq sTarqT -rt zl
$rdrn,/ rqr{rifl fr--ftTq / ffi / wrT-frq lT.aq
d fr?Feun$q sft f

(B) If the pervious erlployntent \,va-s under the Government o1"

Indid, z State Government/an t-lndertaking ou,ried or controlled
by the Governnrent o{- India or a State Ciovern-ment/an
Autonontous Body/tJni versit i, Ilocal Bod1,.
crq.T d;flq frftiT tfiT (snqri ilqr) ftq-qr{fr,
3rTqi
1e6s E-{-d srjsq ]ffi
3TerqT d f,66 1rtr qr6 d
dft-s q{ t{qT E}S efr? TqT oilqd frv_€ oTg
W iil{cr{ frt rri tl Eqr +p1r fu qri
GTp-rqT tfiT wlrkl fuT wri iF rrsru o{stcrT ilrf,B-fi $q
t Grrqeht W r{rrrkr fuq 'rri d Td, qrq Eht drft-s fr
3illii wd_o-qq ,Tril qqT?
II'1ou had lefl service ort giving a rnonth's notice under Rr-rles of
the Central Civil Serviues ("I-ernpc)r'al')' Service) Rules, 1965. or an),
sirlilar corresporrding il,ules \vcrre an), disciplinary' proceedings
fi'amed agair-rst \'olr or had vou l-recrr callec! Lrp()n to explairr voln'
cotlducl in irt)'l,'tattei'at the tirtte .\'oii {jc\ic notice ol'tenltination o1
service. ol' at a sr-rbsequertt da1c. belilre ),oLrr set'\/ices actr-rally
terrl i natcd'/
 5

12 (i) (o) q.rn ailqC m"fi Fr-irrnR fuqT rrqr Bi

6T/Tfi
(a) I{ave..}/ou ever been arL-ested?
YesNo
(is) q'il o*fr oil-s cr{ TfiqqT qar t?
(b) Have yorr ever been prosecuted?
6I /T&
YesA{o

('r) q{n m.ft oilTqi frvisf, d {rqT wrT tz

(c) Have you ever been kept under dete,tion?
6T / =rSI
Yesllrio

(q) rfl o*ft srTqm) Twqq-q fu-rn rrrn tZ ET/qfr

(d) Have you ever. been bound down?
YesA.Jo

(E) qfi fu-{ft frf$--ilqmq i strrr q{ q;fl elefcos el"rT'*Z

(e) Have you ever been fined by a Court of Lau,?
6T / TTI
YesNo
(q) qqr mfi ffi ffi-=qiqraq i fuift s,rq-flq d ftr oTrqqT) a/q€r
Eifi Rr€ fuqT BZ
(0 ever been convicted b), a courr of Law for any Yes/No
ffiJ?u
(E) qqT mfr ffi ftTqfr-€rcrq oTzril ffi eFrl *sTerfi 6I /=ffi
sTthffr"i rrwlTq t *lrqo'r frxft .rfren q ffi * ++l *
3TQtcrT qft,qil FITT t'U
(g) Have you ever been debarrecl fi'om any examination o1 rusticated Yes/lrio
by any University or any other educational authority/institution?

/-\ ( tF?fi ffi

("U wI itrr
E)-fi 3ilzil,T 7wffi znm oilq},T i 6T / q-d}
s.rfr ffi .ffieil /am t orTqoT qRyd/c{-q-rq
EilR-d frrqT tZ
(h) Have you ever been cJeban'ed/disqualified by any Public Ser-vice Yes/No
Comrnission/Staff Selection Comrrrission for any of its Exarnina-
ti on/S el ection ?

(s) TqI qE {rrtlrcrt qq7 q-{i d wrq ffil frf}-=qr"n€rq n 6r / q-sf

srqd fr-s-€ mti TnETTT o.fHd B?
(i) Is an1, case pelrding against you in anl,Cour.r of l.alv at the tinre
Yes/lr]o
of fllling up rhis Attesration lror-rn?

(q) qqT err H.rqlrH wr{ -T(a ETq furft ffi GTsrqr 6I / =rS
3r-T Yle{FFo enfk+xurl€{aflq d 3TTqd fr-sE ,Dt$ qrErcTT
cfrn *z
(it Is any case pending against;,s1r in anl,Urriver.siry gr.anl, s111.,.
Yes/No
educational authority/lnstitution at the tirne of fi iting up this
Attestation For-rn ?

F) ?rqT Tfffi-R d li-q=arirefr{ oTqcr sr-q ft#} H{eryq aT /q_s

i) qtqmT rmd5Ef, frqT rrqrlERsF ftrqT WTlftlDr-rET
'Tq.r 2

(k) \\rhetirer discharged/expr:llecl/u,ithcfi'au'n fi'opr an)i tlaipirrg ins-

titution under thJ Govenrnrent or other-u,ise? YesAtJcr

(ii; qR qrn -Tq-& wrq w-trqd grd .F-t "g111" trt -3 m

z16
ts-fr T6-{i / ft-{rTflT-fr / F{tTrd 7 a*rns / qiisd-q ww
/
enR d ert q eilr / aqqr ftr{fr ;ryq6-q/ftyer6giporq /
gffim qrri)-6iuT 3il.ft q nfun rrqq dl q.ffi d
\/ wf
di dr
If the alts\\/el'ti) an)'of tlre abol,e mentioned qtrestion is'\r[:.S', give
f ull of t he case l arr est/detenti o rl tinel con vi ct i or/sentence/
parti cu l ars
pullishrl]et'tt ctc. and/or the nature of the case pending in tlre Cogrt/
Unit'et'si\'/E ducational Author it\ etc. at the tirne of fi llirrg up
this Fol'rn.
 f.
b
-..

qle:- (i) ?qqT E{r qq, d "sr$q" ii ftrd "#rff" o} *t td

NorE: Please also see the "wARNING"
r

at the top of this Attestation Form.

(ii) rcho- qfi o-t ftftrts Bni -6i" si*j-si ".r€i" -"+-sT *fr rT,ra-i rt, -*. or frqr .;nq r
Specific answers to each of the questions should be given by striking out .yes' or ,No, as the
case may be.
------------- --:---.- ---
13. . .
orri et d tfr d qfrilqf qrq oTerqr -{srd
d m,
"fr
qttm} rrr+i e} r
Names of two responsible persons of your locality or two references to whom you are known.

t.

2.

q trrqftEr t sYft-d o-{dTlo-{fr ( f6 ti qra gn frfuo q-S/qfr t r

I solemnly declare that I have not got more than one wife/Husband living.

q qqrFro
E. fu. +fi EFrm-rfi f,alr furfl"H d ei-grm sw\-.m t1.1fl q-S der Wf d r f; fu=fi Q-tfi
qRR€rmi r) er-q,T-d "Yi-*"t
1t{r-d o-ro q e-coTfl +6.ff d'q-q}q qnTl#+ qro r ^
"-st
I certily that the foregoing information is and complete to the best of my knor.vledge and belief Ir srrr not o
anr rrvt
-correct aware of any
circumstances which might impair my fitness for employment under Government. -

sT?q?ff d rr<rerq
Signature of Candidate

dffiis
Date

TAI;I
Place
 7
q6.[l-{ !'IIIUT -qrt
IDENTITY CERTIFICATE

(trqM -qr{ qi fts fr fr frdS \rf, &, gm EfrIeR fuq wq I

(Certificate to be signed by any one of the following)

1. &q orqdrtrw{w'Ra'qlqq'Ed 3{lffi t

Gazetted Officers of Central or State Government.

EIr{ Ar q{ {6a t
2. Bq ffi4{ & & 1giq-d s{?.ET ftErffi'rr-d errqff o{q-fl sst qmr-fudr 7 ffiq-45'where r

Members of parliament or State Legislature belonging the candidate or his

to the constituency
parent/guardian is ordinarily resident.
3. sq-qqTrnq@ 7 erle-orfrt
Sub- Divisiona I Magistrate/Off icers.

4. frNftq-d qffufi fi qfu-*-d a-dtrirdr{ 3{qEr qlqd srl d-dsd-dR I

Tehsildars or Naib/DePuty Tehsildars Authorised to exercise magisterial powers'

q-d epqrffi 3tq-fr q--dr{ srflql o1 d t
s. 3-q qr;q-dr qTW qrf,/ trikq / €-etr & q{rarErd / ?-sfls{
principal/Head Master of the recognized School/College/lnstitution where the candidate studied last.
6. uu-sfufl-€ sIfYm-rfrt
Block DeveloPment Officer.
7. freqrs{t
Post Masters.
B. iiqrrdfttarot
Panchayat lnsPectors.

q.qrfrrf, f-qr oren B f-f f 2 f / Eq.r$ ..i....... ..........

---:--6,---:.

. .. Efr q-&if t qr+ar E 3i{ +fr qr+orfr q frsrs &

eEsruts-{hrmr f{qqffie-frtt
Certified that I have known Shri/Smt./Kumari
Son/daughter of Shri for the last - Years

him/her are
months and that to the best of my knowledge and belief the particulars furnished by
co rrect.

dter€ 6trrqfl
Date Sig natu re

B{T;[ ........,..... [d;IH 3tq-ql €R eht qm fg6-t & ert[)

place Designation or Status and address (with seal)

olqf-dq arur rfl qrqrfi

(TO BE FILLED BY THE OFFICE)

(i) ffi *.t qTA uTfM cDI qFI, rlffrq d?fl W rrf,i I

ru#u, designation and full address of the appointing authority'

(ii) e{rqff il{ s{IaE-{ ft-qr rrqr {6 w{, fus w @ fu fqqri fr-qr qr rA B r

Post for which the candidate is being considered.

FORMAT FOR FOREIGN REFERENCE OF SELF I RELATIVE STAYING OR
vlslTED ABROAD.
Additional 0a0e mav be used if required
1, Name of the Candidate

2. Name of Foreign Vb
Resident

3. Father's/H usband's Name

(in respect of col .2)

4. Relation with the candidate

5, Date of Birth

6. Place of Birth

7, Permanent Address

8. Present Address

9. Address of place of stay

during foreign visit

10. Occupation

11 Occupational Address

12. Nationality

13. Religion

14, Contact No,

15. Duration of foreign stay

16. Passport No.

Signature:

Name of the candidate:

Roll no.:

Post Applied for: