FORM G : ATTESTATION FORM (Submit in Triplicate)
NATIONAL INSTITUTE OF TECHNOLOGY, ARUNACHAL PRADESH, YUPIA, Pin-791112
(Established by MHRD, Govt. of India)
Ph No: 0360-2284801Fax No: (0360) 2284972,
Website; www.nitap.in
E-Mail: /
/ 1. The furnishing of false information or suppress of any factual information in the Attestation Form would be a disqualification and is likely to render the candidate unfit for employment.2. If, convicted, debarred etc. subsequent to the completion and submission of this form, the details should be communicated immediately to NIT, Arunachal Pradesh failing which it will be deemed to be a suppression of factual information.
3. 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.
1. Name in full (in block letters) with aliases, if any, (please indicate if you have added or dropped at any stage any part of your name or surname.
2. (a) Present address in full (i.e) Village, Thana and District of House No, Lane / Street / Road & Town and name District H.Q.
(b) Home address in full (i.e) Village, Thana and District of House No, Lane / Street / Road & Town and name District H.Q.
(c) If originally a resident of Pakistan the address in that Country and the date of migration to Indian Union.
3. Particular of place (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.
FROM / TO / Residential address in full (i.e) Village / Thana / Lane / Street Road & own / Name of District H.Q of the place Mentioned in the preceding place
Name / Nationality (by Birth) or domicile / Place of birth / Occupation (if Employed give designation and full address) / Present postal Address (if dead give last address) / Permanent home address
1 / 2 / 3 / 4 / 5 / 6
(i) Father’s name (in full) with address if any
(ii) Mother’s name
(iii) Wife / Husband name
5. Nationality
6. (a) Date of Birth
(b) Present age
(c) Age at Matriculation
7. (a) Place of birth / District and State in which Situated
(b) District and State to which you father originally
belongs.
(c) District and State to which you belong
8. (a) Your religion
(b) Are you a member of SC/ST/OBC and if yes, state the name thereof
9. Educational qualification showing place of education with years in school and college since 15 years of age.
10. (a) If you have at any time been employed, give details
Designation of post held / description of work / Period / Full address of the office Firm / Institution / Full reason of leaving the service
From / To
(b) If the previous employment was under the Govt. of India or State Govt./or owned or controlled by Govt. of India or and autonomous body/University/local body. If you had left service on giving a month’s notice under rule 5 of the CCS (Temporary Service) Rules 1949, or any similar corresponding rules were any disciplinary proceeding farmed against you or had you been called upon to explain your conduct in any matter at the time of notice of your termination of service or at a subsequent date before your services were actually terminated?
11. Have you ever been arrested, prosecuted kept under detention or bound down/fined convicted by a Court of Law. If Yes give details / Yes or No
13. Names of responsible persons of your locality or two references to whom you are know. / 1.
2.
3.
I certify that the foregoing information is correct complete to the best of my knowledge and belief. I am no aware of any circumstances which might impair my fitness employment in NIT, Arunachal Pradesh
Signature of the Candidate
Date : ______
Place : ______
IDENTITY CERFICATE
(Certificate to be signed by any one of the following)
1. Gazetted Officer of Central or State Government/ Registrar of any IIT/NIT/Central University.
2. Members of Parliament or State Legislative Assembly
3. Sub-Divisional Magistrate / Officer
4. Tehsildars or Naib / Deputy Tehsilders authorized to exercise Magisterial Powers.
5. Principals/Headmasters of all recognized Institutions.\
6. Block Development Officers.
7. Panchayat Inspectors.
Certified that I have known Shri/Smt/Kumari/Dr. ______Son/Daughter of Shri/Smt ______for the last ______years ______months and that the best of my knowledge and belief the particulars furnish by him/her are correct.
Place : ______Signature : ______
Date : ______
(Designation of Officer and Address)
TO BE FILLED BY THE OFFICE
1. Name, designation and full address of the appointing authority / National Institute of Technology, Arunachal Pradesh, PO – Yupia, Dist. – Papum Pare, Pin : 791112, Arunachal Pradesh2. Post for which the candidates is being considered
FORM TO BE FILLED BY NIT, ARUNACHAL PRADESH EMPLOYEE ON FIRST EMPLOYMENT
i. / Father
ii. / Mother
iii. / Wife/Husband
iv. / Son(s)
v. / Daughter (s)
vi. / Sister(s)
2. Close relation resident in India who are of non Indian Original
i. / Fatherii. / Mother
iii. / Wife/Husband
iv. / Son(s)
v. / Daughter (s)
vi. / Sister(s)
I certify that the foregoing information is correct and complete to the best of knowledge and belief.
Signature ______
Designation : ______
* If in public service, give full particulars regarding designation of post held, name of Department/Office etc where employed and the date of such employment.
Note : 1. Suppression of information in this form will be considered a major departmental offence for whish the punishment may extend to dismissal from service.
2. Subsequent change, if any, in the above date should be reported to the Head of Office/Department, at the end of each year.
OATH OF ALLEGIANCE
I, Shri/Smt/Kumari/Dr. ______Do swear/solemnly affirm that I will be faithful and bear true allegiance to India and to the constitution of India as by law established, that I will uphold the sovereignty and integrity of India, and that I will carry out the duties of my office loyally, honestly, and with impartiality.
(So help me God)
(Signature of the employee with date)
1. Name : ______
2. Designation : ______
3. Date of Birth : ______
4. Place of Birth ______
5. Nationality : ______
6. Permanent Home Address : ______
7. Present residential Address : ______
Signature of the employee
Date: ______
DECLARATION OF HOMETOWN
I declare that my home town is ______
(Name of the place and full address)
* (i) I am required to visit it regularly for discharging my domestic and social obligation.
* (ii) I/My family owns residential property there.
* (iii) My near relations are permanently residing there.
* (iv) I had been living there for ______years before joining service in NIT, Arunachal Pradesh.
Signature of the employee
Place : ______
Date : ______
* Please (√) mark whichever is applicable
DECLARATION BY NEW ENTRANTS TO NIT, ARUNACHAL PRADESH SERVICE
Shri/Smt/Kumari/Dr. ______declare as under
*(i) That I am unmarried / a Widower / a Widow
*(ii) That I am married and have one spouse living.
*(iii) That I have entered into or contracted a marriage with another person during the life time of my spouse. Application for grant of exemption is enclosed.
2. I solemnly affirm that the above declaration is true and I understand that in the event of the declaration being found to be incorrect after my appointment, I shall be liable to be dismissed from service.
Date : ______Signature : ______
Place : ______Name : ______
Designation : ______
* Please delete clause(s) not applicable
(FORM – 3)
(See Rule 54(12))
Details Family :
Name of the employee : ______
Designation : ______
Date of Birth : ______
Date of appointment : ______
Details of the members of my family as on : ______
Sl No / Name of the members of family / Date of Birth / Relationship with the employee / Initial of Head Office / RemarksI hereby undertake to keep the above particulars up-to-date by notifying to the head of office any addition or alteration.
Signature of the employee
Date : ______
Place ______