F.No.7/11/2016-CS.

I(A)
Government of India
Ministry of Personnel, Public Grievances & Pensions
(Department of Personnel & Training)
*******
2nd Floor, Lok Nayak Bhawan,
Khan Market, New Delhi -110003.
New Delhi, the 6th August, 2016.
To,
The successful candidates of CGLE, 2015
recommended to Assistant Section Officers
Grade of CSS
(As per list annexed)
Subject: Appointment to the Assistant Section Officers Grade (Group B,
Non-Gazetted) of Central Secretariat Service on the basis of
Combined Graduate Level Examination, 2015 - completion of preappointment formalities thereof.
Sir/Madam,
I am directed to say that Staff
Selection
Commission
has
recommended candidates for appointment to the Assistant Section Officers
Grade of Central Secretariat Service on the basis of Combined Graduate
Level Examination (CGLE), 2015. Dossiers of most of the recommended
candidates have since been received in this Department, as per the
annexure to this letter. Though utmost care has been taken while preparing
the list annexed, candidates are however advised to cross check their
particulars with their results declared by SSC.
2.
All the successful candidates recommended to Assistant Section
Officers Grade of CSS are required to submit the following documents
immediately:
(i)
(ii)

Willingness to join the post

Four sets of Attestation Form, all sets duly filled in ink.
[The candidates may take print out (back to back) of the
Attestation Form attached and should carefully fill in the forms.
No point in the form shall be left blank. The photograph pasted
on all four sets should be signed by the candidate. Specific
answers to each of the questions in point 15 of the form should
be given by striking out Yes or No as the case may be and not
by tick mark . The candidates should fill in the point 10 also
even if it is same as in the points 2 or 3 of the form]

3.
The candidate who in the point number 10 of the attestation form
indicates his having resided in Delhi should additionally send the selfattested copies of the following documents and the soft copies of the same
by email at kumar.m13@nic.in
(a) One passport size photograph in JPEG format (less than 20 kb)
(b) One copy of photo identity proof in JPEG format (less than 200kb)
(any one of the following)
(i)
(iii)

PAN card
Election ID

(ii)
(iv)

Driving License
Aadhar Card

(c) One copy of residential proof in JPEG format (less than 200 kb) (any
one of the following)
(i)
(iii)
(v)
(vii)

Passport
Telephone Bill (landline)
Passbook
Rent Agreement

(ii)
(iv)
(vi)
(viii)

Electricity Bill
Ration Card
Utility Bill
Others

4.
Candidates should ensure that the requisite documents reach the
undersigned at the address mentioned hereunder, latest by 20th August,
2016.
The Under Secretary (CS.I-A)
CS.I Division,
Department of Personnel & Training,
2nd Floor, Lok Nayak Bhawan,
Khan Market, New Delhi -110003.
5.
All the candidates residing outside Delhi are also advised to appear
before the Civil Surgeon/Principal Medical Officer/Chief Medical Officer of
the District where the candidates are presently residing, for the medical
examination to determine their fitness for the Government service. The
candidates are required to give a statement and declaration regarding
his/her health in the attached form in the presence of Medical Officer. The
medical examination report and declaration in original shall be furnished to
this Ministry as soon as possible. The medical certificate of fitness should be
in the prescribed format, a specimen of which is attached. In case any other
letter is required by the Office of CMO concerned, the undersigned may be
contacted. (Candidates residing in Delhi will be advised about their
medical examination in due course.) However, if the candidate is already
in government service, instead of obtaining a fresh medical report, they may
produce this letter to their controlling authority to enable them to forward
an attested copy of their medical examination report obtained at the time of
appointment, to the undersigned.

Annexure
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Roll No.
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Name
Prashant Kumar Jha
Meenal Garg
Dipankar Chatterjee
Vipin Kumar
Deepak Kapoor
Pooja Chugh
Manish Kumar
Abhishek Banerjee
Ankit
Deepika Adlakha
Vivek Vasan
Raghav Gund
Sachin
Rahul Goyal
Digvijay
Jyoti Agarwal
Parika Goel
Rahul Bansal
Deeptanshu Jain
Ankur Goyal
Anirudh Adigaur
Aanchal Bhaskar
Ankit Mittal
Neeraj
Vijay Kumar
Rahul Choudhary
Jayant Gandhi
Ankur Garg
Praveen Singhal
Kunal Garg
Aakash
Sunil Rana
Kanika Sharma
Hemant Dalal
Surabhi Samariya
Shekhar Kumar Prasad
Vijay
Ankit Khasa
Aakash Aswani
Shivam Tyagi
Arpit Gupta
Kapil Kumar Mudgil
Monika Jain
Rakhi Gupta
Piyush Dabas
Garima Madaan
Krittika Saha
Ritu
Shikha Kumari
Shreyas K
Vikram Singh

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Gagan Deep
Kanika Bansal
Ashish Kumar Shrivastava
Sumit Khatri
Priyavart
Rohit
Yashank Pathak
Archit Jain
Umesh Kumar
Shraddha Singh
Rahul Thakran
Nipun Jain
Lalit Sharma
Madhuri
Deepika Sharma
Ravinder
Monica
Annu
Gautam
Naveen Kumar Sigroha
Ishant Gupta
Nidhi Choudhary
Divya
Vipul Kumar Gupta
Aditi Joon
Takdeer Hooda
Keshav Rose
Digvijay Sharma
Sumesh
Saurabh Bidhuri
Sanjeev
Piyush Sharma
Sheetal Singh
Ankush Sharma
Vishal Bharadwaj
Anand Krishan Mangal
Yasir Khan
Vivek Gupta
Ankit
Neelabh Singh
Sourabh
Anuj
Parul Bhati
Dipika Rana
Ankit Madiyan
Ashish Raghav
Shammi Narang
Swati
Maninder Singh
Jaideep Mathur
Shivang Bhardwaj
Vaibhav Rana
Sibhu Kumar
Sakshi Gautam

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3010032407
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Prashant Kumar
Manoj Kumar Sharma
Vaishali Panwar
Yamini Goyal
Amit Sheoran
Jyoti Nagpal
Pooja Chaudhary
Girish Dube
Tarun Ahlawat
Kunwar Singh
Sourav Bhatia
Amit Kumar
Vipin
Ritvik Lakra
Saurabh Chahal
Ravinder Dalal
Aditya Singh
Shubham Goel
Megha Menon
Ritesh Goyal
Satish Kumar Sharma
Taruna Kapoor
Kuldeep Singh
Lokesh Kumar
Mohd Farookh
Kamini
Dheeraj Dahiya
Anand T R
Krishnender Singh Tanwar
Parvin
Vishal Robin
Raman
Nirnit Kumar
Ayush Goyal
Sidhant Khajuria
Pravesh Kumari
Ankit Mohan
Sanjay Singh
Rekha
Naveen
Upasana Goyal
Anika Gugnani
Shikha Rungta
Mohit
Poonam Sharma
Manit Sinha
Amit Dahiya
Bharti
Amanpreet Singh
Anil Kumar
Neeraj Kumar Vishnoi
Vivek Kumar
Vinay Aggarwal
Ankur Sehrawat

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Pratibha Srivastava
Ankit
Nupur Jain
Pooja
Nitesh Goel
Neha Aggarwal
Gaurav Gupta
Mohit Dalal
Anjali Gupta
Bhupendra Singh Rathore
Jaspal Singh
Amandeep Singh
Sri Harsha Parupudi
Girish Punjabi
Prasanjeet Tripathi
Rohit Kumar Singh
Shivani Jangid
Deepak Kumar Malik
Aditi
Harit Krishan Chaudhry
Rahul Dabas
Rahul Kumar
Amit Kumar
Naveen
Preeti Sharma
Sanjay
Priyanka
Sanjay Maan
Vibha
Sudhanshu Shekhar
Sunil Kumar
Vaibhav Dhawan
Prabhuta Garg
Ankush Bamel
Sweta Bishnoi
Aakash Garg
Nipun Sharda
Chaitanya Krishna Agarwal
Mohinder Pal Goyal
Hitesh Kumar
Sahil
Aditya
Jyoti Dangi
Snehdeep Mishra
Yogender Kumar
Siddharth Chaudhary
Anjali Singh
Vipul Garg
Neeraj Priya
Himanshi Saxena
Amit Batra
Anirudh Rajpurohit
Ankita Gupta
Irfan Ahmed Khan

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Bipin Bhatt
Rashi Jain
Upender
Neeraj Nara
Akshay Pilani
Nitu Katariya
Manish Kumar
Princy Jain
Ashish Grover
Vikas Jangra
Deepti
Neeru
Chetan Kohli
Tanuj Mangla
Ankush Saxena
Ankit Kumar Sen
Srikanth Prasad J
Sachin Balhara
Rajat Jindal
Sumit Dalal
Apoorvjeet Singh
Anuja Katara
Deeksha Rawat
Ajay Singh Chauhan
Shivendra Tiwari
Amarjeet Mohil
Sabahuddin Abdur Rahman
Vibha Jain
Mukesh
Bhavya Agarwal
Mohit
Pushpa
Vishal Chandra
Abhishek Bhardwaj
Rajat Bansal
Shivansh Pathak
Yogesh Kumar Sharma
Harsh Kumar Garhwal
Surendra Singh
Vikram Pal
Radhika
Kishan Kumar
Rishabh Jain
Udit Sah
Rahul Goel
Payal Sharma
Ankur Tyagi
Goldi Kumri
Vipul Vikram
Himanshu Sharma
Kapil
Abhinav Arora
S Ramamurthy
Bhawna

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Vikrant Ahlawat
Gautam Singh
Renu Yadav
Manish Goyal
Arun Sinhmar
Amit Prasad
Mukesh Kumar Verma
Mannu Kumar
Nishant Dahiya
Shubham Goel
Naveen
Jitin Kumar
Shashank Goyal
Vikrant
Neeraj Jha
Rajesh
Gautam Gunjan
Jyoti Jangra
Maneela
Sanju
Manju Kumari
Irfan Nasim
Vinod Kumar Pal
Deepika
Nisha Kumari
Abhijeet Sinha
Vipin Kumar
Ravinder Kumar
Arjit Singh
Mohammad Sharik
Subhash Chand Yadav
Anurag Chopra
Bhupender Singh
Preeti Yadav
Saurabh Gupta
Pankaj Yadav
Vandana Yadav
Arvind Kumar
Nakul Yadav
Manish Ranga
Ankit Sharma
Manbir Singh
Sunil Kumar
Manju Yadav
Rakesh Kumar
Rohit Kumar
Ritesh Kumar
Vikas Kumar
Vivek Kumar Keshri
Nandan Kumar Sah
Vikas Kumar Pal
Ravi
Deepak Kalonia
Sudheer Thumma

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2201146407
2201218068
2402017247
2201206350
2201385477
2201331405
2201425202
2405080932
2201397874
2201404064
2201395739
2201325768
2201423502
2405067709
2201095973
2201315749
2201399761
2201377021
2201331426
2201409448
2201415606
2201223430
2405069042
2201301786
2405134251

2238
2240
2243
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2256
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2279
2286
2306
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2401
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2408
2414
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2419
2442
2443
2444
2468
2482
2483
2486
2488

Shradha
Jasmine Nath
Kartika Sharma
Pradeep Kumar
Ashish Yadav
Umesh Kumar Chanderwal
Harshvardhan Patel
Manoj Kumar
Karun Parihar
Pawan Kumar
Sudhir Kumar Pal
Pardeep
Rohit Kumar
Manoj Kumar
Naresh Kumar
Sanjay Sahu
Rahul Sharma
Seema Choudhary
Kailash Chand
Prashant Kumar
Nitin Kumar
Mohit Saini
Ranjeet Kumar
Ketan
Priti Yadav
Manju
Anoop N S
Parveen Kumar
Jyoti
Surinder Singh
Ravi Kumar
Priyanka Yadav
Amit Kumar
Sudesh Kumar
Madan Mohan Yadav
Krishan Pal
Arun Singh Gurjar
Mahesh
Tushar Chauhan
Jitender Yadav
Sangit Kumar
Chetna Yadav
Santosh
Mukul Sahdev
Reena Bai
Yogya Verma
Mukesh Kumar
Sumit Kumar
Arvind
Mohd Bilaal
Gajendra Singh
Sunil Kumar
Ajeet Kumar Patel
Anju Bala

376.
377.
378.
379.
380.
381.
382.
383.
384.
385.
386.
387.
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389.
390.
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392.
393.
394.
395.
396.
397.
398.
399.
400.
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405.
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414.
415.
416.
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425.
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428.
429.

2201344253
2201426094
2201355395
2405114941
4410505139
2201232567
2201255781
2201314154
2405105118
2201235402
2201331956
2201351851
2201268047
9001009589
2201371667
2201420067
2201275745
2201224669
2405094752
2402014946
2201357155
2201113519
2405105285
2201219173
2405100623
4410024586
2201159526
2201328243
2201212568
3010072261
9211018888
2201236606
2201329432
2201387006
4405001150
2201292079
2405150294
2201387007
4410088866
8002056386
2201181732
2201329611
3010046447
2201268723
2201320149
2201361743
2405098641
2405147192
2201254275
2201232760
2201195971
2201247549
2201421562
2201253539

2492
2499
2501
2507
2509
2511
2535
2537
2540
2554
2561
2562
2566
2569
2570
2578
2587
2596
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2732
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2737
2738
2745
2756
2763
2764
2766
2771
2772
2773
2775
2781
2782

Ankit
Katkam Dinesh Kumar
Rajeev Ranjan
Praveen Kumar
Monalisa Dutta
Khushbu
Nitin Rohilla
Anil Kumar
Ramkishan Gurjar
Preeti Yadav
Vishal
Pawan Kumar
Rohit Kumar
Ashok Kumar Yadav
Aman Kumar
Deepika
Sonam Katiyar
Nitish Nagar
Shri Ram Yadav
Dilip Kumawat
Ravi
Ashwani
Vikas Prajapat
Neeraj Singh
Akanksha
Sandeep Biswas
Pushpendra Yadav
Arvind Yadav
Parveen Kumar
Sipendra Kumar
Pratap Kumar P
Mahavir Thakur
Amit Kumar Sharma
Kamal Kishore
Animash Paul
Rajeev Ruhella
Rajneesh Soni
Hemant Yadav
Chirantan Das
Avula Krishna Chaitanya
Shakil Ahmed
Arun Pratap Singh
Sri Krishna Pal
Ravi Kumar
Anurag Kumar
Rohit Kumar
Gourav Kumar
Manisha Saini
Vikas
Vinay Kumar
Subhash Yadav
Hemant Kumar
Deepak Bharti
Avinash Yadav

430.
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483.

2201229721
8002051186
2201051800
2201315224
2405154654
2201169255
2201197818
8007010466
2408005003
4405008253
2201390877
2201288544
2406015077
2405119369
2201266111
2201235830
2201306846
2201249731
3003055216
3205004234
2201326500
2406017464
2405109073
2406012617
2201171906
2201297578
3205014020
2201401723
2201262036
2201084958
2201369618
2201369191
4604002592
2201405390
2201147409
2201353490
2201277618
2201032716
2002018387
5105001183
2201385747
2201363848
9211000623
2201270571
2201280046
2201253993
2201289983
2201207684
2201371989
2405134614
2201413418
2005008308
3009063179
2201224168

2785
2786
2789
2798
2800
2804
2807
2814
2817
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2821
2822
2823
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2825
2826
2827
2829
2831
2832
2842
2846
2874
2888
2913
2919
2921
2928
2938
2980
2990
2991
2994
3001
3019
3025
3026
3039
3042
3048
3050
3051
3057
3063
3071
3077
3085
3097
3101
3105
3108
3109
3123
3128

Rakesh Tanwar
Kodam Ravi Teja
Ashwani Verma
Ankit Yadav
Mahfuza Mansoori
Anju Saini
Pooja Verma
Gurugubelli Prasanna Kumar
Bhupendra
Surajit Basak
Diwakar Singh
Ashok Kumar Yadav
Bharat Rogani
Pankaj Kumar Saini
Mritunjay Kumar
Mohit Kumar
Amarkant Singh
Versha
Lawkush Vishwakarma
Rohit Kumar
Rahul Ray
Atul Bamnia
Kiran Meena
Kiran Raj
Dushyant
Vikram Singh
Abhishek Raj Gautam
Ekta Anand
Ravindra Pal Singh
Shailja Singh
Prateek Sagar
Prince Pawar
Amrit Behera
Vikas
Ajay
Naveen Kumar Punia
Sourabh
Kumar Saurav
Vishakha Patiyal
Rima Bogi
Ankit Kumar Shailani
Abhishek Kumar
Raj Kumar
Mohit
Ritesh Dheer
Sumit Kumar
Kamal Kumar
Sakshi
Shubham Tomar
Mohit Tanwar
Ravi Kumar Kalyan
Atul Barswal
Sumit Gupta
Pradeep Singh

484.
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536.
537.

2201227891
2201416982
2201217968
4205006115
2201290844
2201394697
2401003389
2201245047
2201398854
2201155309
2201218913
2201427340
2201216341
2201231828
2201117141
2201326828
2201201067
2201233534
2201131042
2201236772
8201001947
2201230592
2402022776
2201178748
2201139491
2201326271
9001008904
2201284460
2201265877
2201328072
4410025693
2201426065
2201328911
2401015047
2201341193
2405087076
2201347504
2201198211
2201032389
2201421559
2201232045
2201397478
2201394729
2201346527
2201142573
2201398837
2402024068
2201352161
2201224846
2201107765
2201341028
4410086035
2201409461
2201391303

3130
3151
3153
3160
3161
3163
3164
3168
3177
3184
3199
3201
3203
3205
3208
3214
3215
3216
3221
3228
3244
3249
3250
3252
3255
3256
3257
3258
3259
3261
3264
3265
3278
3282
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3292
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3300
3304
3305
3312
3321
3327
3329
3333
3337
3349
3355
3363
3366
3372
3382
3384
3388

Meenakshi
Sonia
Pradeep Kumar Singh
Vishal
Shreya
Rahul
Himanshu Harit
Sandeep Kumar Arya
Yogesh Kumar
Anuj Kumar
Rohit Kant
Ankit Panwar
Sandeep Das Majumdar
Sandeep Raj T
R Mayank
Chandra Dutt Singh
Manish Meena
Kunal Sakarwal
Madhukiran Korrapaty
S Sundardevan
Hema Rani
Sumit Kumar Shirawta
Ramakanwar
Amit Meena
Jai Prakash
Hemant Kumar
Vipin Singh
Kuldeep Singh
Krishan Kumari
Shashi Suman
Raja Sharma
Mamta Meena
Kavish
Ajay Baseta
Parul Malik
Seema Bai Meena
Pooja Rani
Kanika Sihmar
Monika
Pracheta Sateep Satya Prakash
Ranjana Gautam
Deepak Kumar Gautam
Sanjeev
Sanjeev Kumar Kataria
Deepak Rangay
Vikas Kumar
Dinesh Kumar
Kamal Jeet
Bhupender Kumar
Swati
Shiv Raj Meena
Swapna Naskar
Subhendu Kumar Behera
Dinesh

538.
539.
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590.
591.

2405159651
2405142289
2201242651
2405147649
2405059243
2201157678
2201285406
2405151310
2405100131
2201029218
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2201418607
2405102678
2201344832
2405143329
3206124112
2201164660
2201259322
4205082783
2201176843
2405155318
2405094779
2405133951
2405062299
2201165837
2201056626
2405165049
4412000261
2405100530
3001015159
2405138086
2405131461
2405069961
2405160327
2405133072
2201384217
2405069016
2405136589
2405094606
2405064624
2405112172
2405124026
2201256053
2402002484
2201315593
8002009606
2201279478
2407015934
2405147286
2405083608
2201263139
2201351564
2201281519
2201326969

3403
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3631
3642
3649
3659
3663

Vikash Sharma
Ramesh Chand Meena
Lekhram Meena
Vikramaditya Singh Dev
Anita Meena
Mohit Krishna
Imtiaz Ahmed
Shankar Lal Meena
Naresh Kumar Meena
Divyanshu Kr Sah
Kamal Ram Meena
Rajesh Kumar
Naveen Meena
Nancy Hemrom
Neelam Meena
Ranjeet Kumar
Nishant Meena
Sachin Kumar
Deepak Kumar
Vikas Kumar Jha
Rakesh Meena
Ram Prasad Meena
Shiv Pal Meena
Sunil Kumar Meena
Shweta Meena
Lokesh Kumar Meena
Lokesh Kumar Meena
Prashant Kumar
Kamlesh Kumar Meena
Rameshwar
Chandra Prakash Meena
Chandra Prakash Meena
Deepak Khoda
Ramkesh Meena
Bane Singh Meena
Gagan Kumar Kamat
Vinod Kumar Meena
Vachan Singh Meena
Ravi Prakash Meena
Dil Mohan Meena
Sanjay Kumar Meena
Karan Meena
Arun Meena
Hemant Kumar Meena
Vipra Meena
Komaragiri Karthik
Ayush
Anil Meena
Namo Narayan Meena
Namonarayan Meena
Praneet Sharma
Akshay Bhargava
Deepak Subedi
Ruchir Kumar Gupta

592.
593.
594.
595.
596.
597.

2201417904
4410043310
8007007028
9001032734
4405005762
2201237370

3665
3666
3667
3668
3669
3670

Sushant Kumar
Mrinmoy Chowdhury
Yateesh Kandi
Varun Gupta
Romy Mathew
Yogesh

Note: Dossiers not received as yet in respect of candidates highlighted in red colour

To,
The Under Secretary (CS.I-A)
CS.I Division,
Department of Personnel & Training,
2nd Floor, Lok Nayak Bhawan,
Khan Market, New Delhi -110003.
Subject: Appointment to Assistant Section Officers Grade
Submission of documents by candidates of CGLE, 2015

of

CSS-

Sir,
I am to refer to letter No.7/11/2016-CS.I(A) dated 6th August, 2016
of Department of Personnel & Training on the subject mentioned above and
hereby convey my willingness to join the Assistant Section Officers Grade of
Central Secretariat Service.
2.
Four sets of Attestation Forms duly filled in my own handwriting, are
also attached.

Yours faithfully,

Dated _______ August, 2016

Signature:_____________________________
Name:____________________________________________
Roll No. _________________________________
Date of Birth: _________________________________
e-mail:_________________________________
Contact No:_________________________________
CGLE, 2015 Rank (AIR):_________________________________

ATTESTATION FORM

1.
___________________
Affix signed
Passport size
( 5 cms. X 7 cms.
Approx). copy
of recent
photograph
__________________

2.

3.

1.

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
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 services would be liable to be
terminated.

Name in full (in block capitals)

with aliases, if any,
(Please indicate if you have
added or dropped in any stage,
any part of your name or
surname).
Present Address in full (i.e.
Village, Thana and District, or
House No., Lane/Street/Road &
Town).

3.(a)

Home Address in full (i.e.

Village, Thana & District, or
House No., Lane/Street/Road
and Town and name of District
Headquarters)

(b)

If originally a resident of
Pakistan/Bangladesh (erstwhile
East Pakistan) the address in
that country and the date of
migration to Indian Union.

4.

Aadhar Card No. (if available)

5.

Permanent Account Number

(PAN)
(if available)
Nationality

6.

WARNING
The furnishing of false information or
suppression of any factual information in the
Attestation Form would be disqualification, and
is likely to render the candidate unfit for
employment under the government.

Signature

7.(a)

Date of Birth

(b)

Present age

(c)

Age at Matriculation

8.(a)

Place of birth, district and state

in which situated

(b)

District and State to which you

belong

(c)

District and State to which your

father originally belongs

9.(a)

Your Religion

(b)

Are you a member of a

scheduled
Caste/Scheduled
Tribe/Other Backward Class?
Answer Yes/ No

10.

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.

From

To

Residential Address in full (i.e. Village Name of the District

Thana & District or House No. Head Quarter or the
Lane/Street/Road & Town
place mentioned in
preceding column.

Signature

11.

Name (in
full
&
aliases if
any

Nationality (by birth

& or by domicile

Place
birth

of

Occupation if
employed give
designation &
official address

Present postal
address
(if
dead give last
address

Permanent
Home address

a) Father

b) Mother

c) Spouse

12.

Information to be furnished with regard to son(s) and/or daughters in case they

are studying/living in a foreign country:

Name

13.

Nationality by Place of
birth and/ or birth
by domicile

Country in
which
studying/living
with full
address

Date from which

studying/living in the
country mentioned in
the previous column

Educational Qualification showing places of education with years in Schools and

Colleges since 15th year of age:

Name of
address

School/College

(with

full Date
Entering

of Date
Leaving

of Examination
Passed

Signature

14.
(a)

From

14.
(b)

Are you holding or have any time held an appointment 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 or institution?
If so, give full particulars with date of employment up-to date
Period
To

Designation,
Full name & address of
emoluments & employer
nature
of
employment

Reasons for
leaving previous
service

If the previous employment was under the Government of India/a State Government/
undertaking owned or controlled by the Government of India or a State Government/ and
Autonomous Body/University/Local Body.
If you had left service on giving a months notice under Rule 5 of the Central Civil Services
(Temporary Service) Rules 1965, 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
dates(s), before your service actually terminated?

15.
(i)

(Strike out Yes or No as

the case may be)

(a)

Have you ever been kept under detention?

(b)

Have you ever been arrested?

(c)

Have you ever been prosecuted?

(i.e has a charge sheet in a criminal case been filed
against you in any court of law)

(d)

(e)
(f)
(g)

Is any criminal case pending against you in any

Court of Law at the time or filling up this Attestation
form?
Have you ever been convicted by a court of Law for
any Office?
Whether discharged/expelled/withdrawn from any
training/institution under the Government or
otherwise?
Have you ever been rusticated by any University or
any other educational authority/institution?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Signature

(h)

(ii)

Have you ever been debarred / disqualified by any

Public
Service
Commission/Staff
Selection
Commission for any of its examination/selection?

Yes

No

If the answer to any of the 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/Educational Authority etc
at the time of filling up this attestation 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 may be
16.

Names of two
responsible person of
your locality or two
references to whom
you are known:

1)

2)

DECLARATION
I certify that the foregoing information is correct and complete to the best of my knowledge
and belief.
I am fully aware that by providing false information or suppressing material information while
filling this form, the authorities have full right to terminate my appointment letter and I am also liable
for appropriate criminal/civil/legal action as a consequence.
I am not aware or any circumstances which might impair my fitness for employment under
Government.

Date:
Place:

Signature of candidate

TO BE FILLED BY THE OFFICE

i)

Name, Designation and full address of the authority forwarding the form:

Under Secretary to the Government of India

CS.I Division
Department of Personnel & Training,
2nd Floor, Lok Nayak Bhavan,
New Delhi-110003
ii)

Post for which the candidate is being considered.

Assistant Section Officers Grade, Group-B, Non-Gazetted of

Central Secretariat Service

FORM OF MEDICAL CERTIFICATE

I hereby certify that I have examined Sh/Smt/Km. _________________________________

a candidate for employment in the Central Secretariat Service in the Government of
India and cannot discover that he/she has any disease (communicable or otherwise),
constitutional weakness or bodily infirmity, except ________________________________.
I do not consider this a disqualification for employment in Central Secretariat Service
in the Government of India.
The

age

of Shri/Smt./Kum._____________________________________ according

to

his/her own statement is _________ years, and by appearance is about _______ years.

_______________________________
(Signature/thumb impression
of the candidate)
Date ____________________
(To be signed in the presence of
the examining Medical Officer)

(Paste a photograph
of
the
candidate
examined )

___________________________
Signature of Medical Officer
Name__________________________
Address________________________
________________________
Official Seal

(Seal should be spread over

form and the photograph)

Note: The officer making this certificate should be a Civil Surgeon or a

District Medical Officer of equivalent status of a Government Hospital

CANDIDATES STATEMENT AND DECLARATION

(The candidate must make the following statement and must sign the declaration below it
before the medical officer. Attention is specially invited to the WARNING in the Note at
the bottom of page 2.)
1.

Name in full
(in BLOCK letters)

_________________________________________________

2.

Age and place of birth

_________________________________________________

3.

Have you ever had

(a)small-pox, intermittent fever and
other fever, enlargement suppuration
of glands, spitting of blood, fainting
attacks, rheumatism or appendicitis?
OR
(b) any other disease or accident
requiring confinement to bed and
medical or surgical treatment?

_______________________________
_______________________________
_______________________________
_______________________________

4.

When were you last vaccinated?

_______________________________

5.

Have you or any of your relatives been

afflicted by consumption, scrofula, gout,
asthma, fits, epilepsy or insanity?

_______________________________

Have you suffered from any form of

nervousness due to overwork or any
other cause?

_______________________________

6.

7.

8.

Have you been examined and declared fit

for Govt. Service by a medical officer/
Medical Board within the last three
years?

_______________________________

_______________________________

_______________________________
_______________________________

Furnish the following particulars:

Fathers age, if Fathers age at the No. of brothers No. of brothers
living, & state of time of death and living, their ages and who have died,
health
cause of death
state of health
their ages at death
and cause of death

Contd....../-

-2Mothers age, if living, & Mothers age at the No.

of
sisters No. of sisters who
state of health
time of death and living, their ages have died, their
cause of death
and state of health
ages at death and
cause of death

DECLARATION
I declare that all the above answers are true and correct to the best of my knowledge
and belief. I also solemnly affirm that I have not received any disability certificate/ pension
on account of any disease or other condition.

_______________________
Candidates signature
Date: _________________
Signed in my presence.

______________________
Signature of Medical Officer
Name: ____________________
& Designation: ____________________
____________________
____________________

Note: The candidate will be held responsible for the accuracy of the above statement.
By wilfully suppressing any information he will incur the risk of losing the appointment
and, if appointed, of forfeiting all claims to superannuation allowance or gratuity.
(Please take back to back print)