Attestation Form - Gauhati University

GAUHATI UNIVERSITYGOPINATH BORDOLOI NAGAR, GUWAHATI-14ATTESTATION FORM“WARNING : The furnishing of false information or suppression of any factualinformation in the Attestation Form would be a disqualification and is likely to renderthe candidate unfit for employment under the University.2. If detained, convicted, debarred etc. subsequent to the completion and submissionof this form, the details should be communicated immediately to the authority ofGauhati University to whom the attestation form has been sent earlier, failing which itwill be deemed to be a suppression of factual information.3. If furnishing of false information or suppression of any factual information in theattestation form comes to notice of the authority of Gauhati University at any timeduring the service of a person, his services would be liable to be terminated.”Affix signed passport size(5 cm. x 7 cm. approx.) copyof photograph where askedfor1. Name in full ( in block letters) SURNAME MIDDLE NAME FIRST NAME(Please indicate if you have added ordropped in any stage any part of yourname or surname)2. Present address in full(i.e., Village, Thana and District orHouse Number, Land/Street/Road andTown)3. a) Home address in full(i.e., Village, Thana and District orHouse Number, Land/Street/Road andTown and name of DistrictHeadquarters)b) If originally a resident of Pakistan,the address in that Country and thedate of migration to Indian Union.a)b)4. Particulars of places ( with periods and residences) where you have resided for more than one year at a time duringthe preceding five years. In case of stay abroad ( including Pakistan) particulars of all places where you have residedfor more than one year after attaining the age of 21 years, should be given.From To Residential address in full( i.e. Village, Thana and Dist. orhouse No. Lane/Street/Road andTown)Name of the District Head quarters ofthe place mentioned in the precedingcol.

5 (a) Name(Please write the name in fullaliases, if any)FatherNationality( by birthand /or bydomicile)Placeof birthOccupation(if employedgivedesignation &official address)Present address(if dead give lastaddress)PermanentHome AddressMotherWife /HusbandBrother (s)Sister (s)5 (b) Information to be furnished with regard to son (s) and/ or daughter (s) in case they are studying /living in aforeign country :NameNationality(by birthand/or bydomicile)Country in whichstudying/ living with fulladdressDate from which studying/living incountry mentioned in previouscolumn.6. Nationality :7. a) Date of birthb) Present agec) Age at Matriculation8. a) Place of birth, District and Stateb) District and State to which you belongc) District and State to which your fatheroriginally belongs9. a) Your religion :b) Are you a member of a Scheduled Caste/Scheduled Tribe ? Answer ‘Yes’ or ‘No’ andif the answer is ‘Yes’, state the name threof.a)b)c)a)b)c)a)b)

10. Educational qualifications showing places of education with years in Schools and Colleges since 15th year of age.Name of school/ college with full addressDate ofenteringDate ofleavingExamination passed11.a) 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 orinstitution? If so, give full particulars with dates of employment, up-to-date.PeriodDesignation,emoluments andFrom To nature of employmentFull name and address ofemployerFull reason s for leavingthe previous service11 b) If the previous employment was under the Govt. of India. a State Govt./ an undertaking owned or controlled by theGovt. of India or a State Govt. an autonomous body/ University/ Local body. If you had left service on giving amonth’s notice under rule 5 of the Central Civil Services ( temporary Service) Rules 1965, or any similarcorresponding rules, were any disciplinary proceedings framed against you, or had you been called upon to explainyour conduct in any matter at the time you gave notice of termination of service, or at a subsequent date, before yourservice actually terminated ?12 i) a) Have you ever been arrested ? Yes/ Nob) Have you ever been prosecuted ? Yes/ Noc) Have you ever been kept under detention ? Yes/ Nod) Have you ever been bound down ? Yes/ Noe) Have you ever been fined by a court of law ? Yes/ Nof) Have you ever been convicted by a court of law for any offence ? Yes/ Nog) Have you ever been debarred from any examination or rusticated byany University or any other educational authority / Institution ?Yes/ Noh) Have you ever been debarred / disqualified by any Public ServiceCommission from appearing at its examination / selection ?Yes/ Noi) Is any case pending against you in any court of law at the timeof filling up this Attestation Form ?Yes/ Noj) Is any case pending against you in any University or any othereducational authority/ institution at the time of filling up this Attestation Form ?Yes / Noii)If the answer to any of above mentioned question 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/ EducationAuthority etc., at time of 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 maybe.13. Name of two responsible persons of your locality ortwo references to whom you are known.1.2.I certify that the foregoing information is correct and complete to the best of my knowledge and belief. I am not awareof any circumstances which might impair my fitness for employment under Government.Place : ________________________Signature of the candidate.Date : __________________________________________________________________________________________________________________________IDENTITY CERTIFICATE(Certificate to be signed by any one of the following officials )(i) Gazetted Officers of Central or State Government;(ii) Members of Parliament or State Legislature belonging to the constituency where the candidate or his/herparent/guardian is ordinarily resident;(iii) Sub-Divisional Magistrates/ Officers;(iv) Tehsildars or Naib/Deputy Tehsildars authorised to exercise magisterial powers;(v) Principal/ Head- Master of recognised School / College / Institution where the candidate studied last ;(vi) Block Development Officer;(vii) Post-Masters;(viii) Panchayat Inspectors.Certified that I have known Dr./ Mr./ Mrs. / Ms.........................................................................................................Son/ Daughter of.......................................................................................for last ................years...............monthsand that to the best of my knowledge and belief the particulars furnished by him / her are correct.Place : _____________________SignatureDesignation orDate : _____________________ Status :Address :__________________________________________________________________________________________________TO BE FILLED BY THE OFFICE1. Name, designation and full address of the : RegistrarAppointing AuthorityGauhati universityGopinath Bordoloi NagarGUWAHATI - 781 0142. Post for which the candidate is beingConsidered : .....................................................................