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(Sant Gadge Baba Amravati University)
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(Attestation Form)
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1)
Warning : The furnishing of false information or suppression of any factual information in the attestation form
would be disqualification and is likely to tender the candidate unfit for employment under the Government.
2)
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If detained, convicted, debarred etc. subsequent to the completion and submission of this form the details
should be communicated, immediately, to the authority to whom the attestation form has been sent earlier, as
the case may be failure to do so will be deemed to be suppression of factual information.
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If the fact that false information has been furnished or that there has been suppression of any factual information
in the attestation form, comes to notice at any time, during the service of a person his service would be liable to
be terminated.
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Name in full (in block capitals) with aliases, if any
(Please indicate if you have added or dropped at any
stage any part of your name or surname)
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Present address in full (i.e. Village, Thana and District
or House Number, Lane/Street/Road and Town)
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6)
(a) Home address in full (i.e. Village, Thana and District
or House Number, Lane/Street/Road and Town)
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(b) if originally a resident of Pakistan, the address in
that country and the date of migration to the Indian
Union.
Surname
Name
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4) Particulars of places (with periods of residences) where you have resided for 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.
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(e)
official address
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Father
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(a)
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(b) Mother
(4)
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Candidate
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(2) Place of birth of Husband/Wife
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(a)
Exact date of birth
( 31)
(a)
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Name of the District Head Quarter of
the place mentioned in the preceding
Column
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(b)
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Present Age
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Age at Marticulation
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(b) District and State to which you
belong ?
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9) Educational Qualifications showing place of
education with year in schools and college
since the 15th years of age.
Ozr RtT.
Date of
entering
fff/ 4-16Incileizri 9f44gufurm
Name of School / College with
full address
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4-i.
No.
fl se-eatir it-ffi
Date of
leaving
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Examination
passed
1
2
3
4
5
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10) (a) If you have any time employed, given details
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From
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Office / firm or
institution
Period
Designation or post
held or description of work
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Full reasons for leaving
the previous service
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- C 10) (b) If the previous employment was under the Government of
India/ a State Government/ an undertaking owned or controlled
by the Government of India or a State Government/ an
autonomous body/ University/Local body, please State fully
the reasons for leaving/ termination of that appointment.
Whether any disciplinary proceedings framed against you or
had you been called uopn to explain your conduct in any matter
at the time you gave notice of termination of service or at a
subsequent date before your services were actually
terminated?
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11)
(a) Have you ever been arrested/ prosecuted/ kept under
detention, or bound down/ fined/ convicted by a court of law
for any offence or debarred/ disqualified by any Public Service
Commission from appearing at its examinations/ selections
or debarred from taking any examination/ rusticated by any
University or any other educational authority/ Institution?
9 9) (4)
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11) b) Is any case pending against you in any court of law. University
of any other educational authority/ Institution at the time of
filling up this attestation form?
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11) c) Whether he/she is facing any criminal prosecution in any court
and if yes to state details thereof such as case number, in
which court the case is pending, under which section, etc.
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[If the answer to (a) or (b) or (c) is 'Yes' fill particulars of the case, arrest detention, fine, conviction, sentence,
etc. and the nature of the case pending in the Govt./University/ Educational authority etc. at the time of filling up this
form should be given]
Place :
q4m-41 .-cliffft/signature of the Candidate
R92W
Date :