Annexure-I
Name: Affix passport
Parent Department: size (7cm X 5cm)
Recent
Present Department: Photograph
Designation:
Employee ID:
(To be filled in block letters)
1. The furnishing of false information or suppression of any factual information in the
Attestation Form would entail disqualification, as is likely to render the candidate unfit for
employment under the government. If suppression of any factual information comes to
notice at any time during the service of a person, his/her services would be liable to be
terminated without any further notice.
2. If detained, arrested, prosecuted, bound down, fined, convicted, debarred, acquitted etc.
subsequent to the completion and submission of this form, the details 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.
3. (a) Name in full : _____________ ______________ _____________ ________________
(First Name) (Middle Name) (Last Name) (Surname)
(b) Sex : ____________________________________________
(c) Alias (if any) : _____________________________________
(d) Category : _________________________________________
(e) Blood Group : _______________________________________
(f) Name at birth, if different and any other names, surnames used at any stage: _________
_______________________________________________________________________
4. (i) Present Address
a. House No./Name :
b. Locality/Street :
c. Town/Village :
d. Police Station :
e. Post Office :
f. District :
g. State/UT :
(ii) Permanent Address
a. State/UT :
b. District :
c. House No./Name :
d. Locality/Street:
e. Town Village :
f. Police Station :
g. Post Office :
(iii) Please mention original native place, if the family migrated after 01.01.1990:
a. State/UT :
b. District :
c. House No./Name :
d. Locality/Street:
e. Town Village :
f. Police Station :
g. Post Office :
(iv) Domicile Certificate details :
(v) Educational Qualifications (Academic / Technical) showing places of education with
years in school, colleges and universities since 15 years of age:
Name of Date of entering Date of Leaving Examination Passed
school/college/University
(with full address)
5. Mobile numbers used during last 5 years :
6. Email and social media/web based portal accounts :
7. Registration number of vehicles owned/used :
8. Bank / Post office account numbers :
9. PAN number :
10. Aadhaar Number :
11. Passport number :
12. Date of Birth :
13. Place of Birth (village/town, district, state, country):
14. Nationality :
15. Religion :
16. Details of postings and promotions earned from the date of appointment
(applicable for re-verification cases)
(a) Postings
Office and Place From To
(b) Promotion
Office and Place From To
17. Joining Details
i Recruiting Agency
ii. Date of Appointment
iii. Initial Joining Department
iv. Date of Joining
v. Employee initial cadre
State/Div./District
vi. Gaz./Non-Gaz/Class-IV
vii. Order No.
viii. Initial Joining Office
ix. Designation
x. Permanent/Temporary Employee
18. Salary Details
Current Pay Band PAN No.
Grade Pay Basic Pay
Personal/Specific Pay GPF/PRAN No.
Dearness Allowance Deduction Type
/Dearness Pay COLA GPF/CPF (NPS)
YES/NO
Total Salary (Including Allowance)
Name of Salary Bank Saving A/C No.
Branch
Entitlement of Pension (Defined benefit/NPS)
Contribution to NPS (Employer + Employee)
Accumulations under NPS (including earnings from investment of
contribution) :
19. Employee Office details
Employee office details
Current Designation Current Post
Current Cadre: Current Office
State/Div./District
20. Whether Govt. accommodation allotted in Jammu/Srinagar:
Details of accommodation, if hired (Y/N)
21. Particulars of family members:
Relation Name Occupation Present Address
Father
Mother
Wife/Husband
Son(s)
Daughter(s)
Brother(s)
Sister (s)
Step son (s)
Step daughter (s)
22. Particulars of In-Laws:
Relation Name Occupation Present Address
Father-in-law
Mother-in-law
Brother-in-law
Sister-in-law
23. Particulars of places (with period of stay) where you have resided for more than one year at
a time during the preceding 5 years. In case of stay abroad (including Pakistan/PoK),
particulars of all places where you have resided for more than one year after attaining age of
18 years:
From To Full address including Village, Police Station, Post Office,
Town, House and Street No., Contact No. etc.
24. Please furnish details of your foreign visits for the last five years:
From To Country visited, purpose of visit, details of host with whom
he/she stayed
25. Details of personal contact with Government officials of foreign countries:
Name, Designation & Country of officials Meeting circumstances
26. Please furnish details of the foreign visits of your spouse for the last five years:
From To Country visited, purpose of visit, details of host with whom
he/she stayed
27. Details of persons (other than family members) residing with you:
Name From To Relevant contextual information
28. Details of family members (Indian and Non-Indian) working in foreign missions or in foreign
organization including foreign concerns in India & Abroad:
Name & Current Nationality Place/Country Occupation/ Additional
Relation Address of birth employer relevant
details information
29. Details of children studying / living / working abroad :
Name & relationship Details of course being persued, college /
university; employer details and residential
address
30. Details of previous employment under Central or State Government or a Semi Government
or a Quasi Government body or an autonomous body or a Public Sector Undertaking or a
Private firm of Public projects:
Period Designation, Full name & Reasons for
From To emoluments & address of leaving previous
nature of employer service
employment
If you had left service on giving three months notice under Article 230 of the J&K CSR
Volume-I, 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 gave notice of termination of service, or at a subsequent date(s), before your service
actually terminate?
31. (a) Have you ever been arrested ? YES/No (If yes give details) :
(b) Have you ever been prosecuted ? YES/No (If yes give details):
(c) Have you ever been kept under detention? YES/No (If yes give details):
(d) Have you ever been bound down ? YES/No (If yes give details):
(e) Have you ever been fined by a court of law? YES/No (If yes give details):
(f) Have you ever been convicted by a court of law? YES/No (If yes give details):
(g) Have you ever been charged before a court of law with an offence for which you were
convicted, conditionally discharged, placed on probation or acquitted? YES/No (If yes
give details):
32. (a) Whether discharged/expelled/withdrawn from any training programme in Government /
Private institution? YES/No (If yes give details):
(b) Have you ever been debarred from any examination or rusticated by any university or
any other Educational authority/institution? YES/No (If yes give details):
(c) Have you ever been debarred / disqualified by any Public Service Commission/Staff
Selection Commission for any of its examination/selection? YES/No (If yes give details):
(d) Is any case or enquiry / departmental proceedings pending against you in any court of
law (including civil litigation) or any other authority. YES/No (If yes give details) :
33. Have you ever been a Prisoner of War or held in enemy country for any duration? If so, give
details :
34. Are you an Arms licence holder? If so, give details of license and Arms in possession:
35. Details of outstanding loans, borrowings and financial liabilities of self and spouse:
36. (a) Details of membership of cultural or social organizations associated with or assisted by a
foreign mission or organization:
(b) Details of membership of family members and close relatives of cultural / social
organization which is associated with foreign mission or organization:
(c) Details of membership of or association with prescribed / prohibited / banned
organization viz JeI:
(d) Details of membership of club/society/association/trust/charity and similar bodies:
37. (a) Details of membership of any political party / organization and participation in any
political activity :
(b) Details of membership of family members / close relatives with any political party /
organization and participation in any political activity:
38. Details of legal proceedings against / prosecution of family and close relatives:
39. Details of family members / close relatives having been prisoner of war or held any enemy
country for any duration:
40. Name, address and contact numbers of two responsible person of your locality or two
references to whom you are known:
Declaration:
I Certify that the foregoing information is correct and complete to the best of my knowledge and
belief.
I am duly aware that by providing false information or suppressing material information while
filling this form, the authorities have full right to terminate my appointment letter/order and I
am also liable for appropriate criminal/civil/legal action as a consequence.
I am not aware of any circumstances which might impair my fitness for employment under
Government.
(Signature of the candidate/employee)
each page to be signed
Place:
Date:
