Attestation Form - Gauhati University

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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.
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Attestation Form - Gauhati University

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