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Police verification/attestation form ATTESTATION FORM WARNING 1. The furnishing of false information or suppression of any factual information in the Attestation Form would be a disqualification and is likely to render the candidate unfit for employment under the Govt. Affix passport size photograph here 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* 3. If the fact that false information has been furnished or there has been suppression of any factual information in the attestation form comes to notice at a time during the service of a person his/her services would be liable to be terminated* i Name in full IN BLOCK CAPITALS with alias if any. Please indicate if you have added or dropped in any stage any part of your name or surname ii Present address in full i*e* Village / Thana / District or House No*/ Lane/ Street / Road / Town and name of District Hqrs. iii a Home address in full b If originally a resident of Pakistan the address in that country and the date of migration to Indian Union 4. Particulars of places with period of residence 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* S* No* From To Residential address in full i*e* Village / Thana / District or Door No* / Lane / Street / Road and Town Name of the Hqrs. of the places mentioned in the preceding column http //www. delta*org. in/download/form Members of family Name with alias if any Nationality Place of Birth Occupation if employed give designation and Office address Present postal address and permanent Home Father Mother Wife / Husband Brother/s Sister/s 5. Information to be furnished with regard to son s and daughter s in case they are studying / living in a foreign country. Name Country in which Date from which By birth or birth studying/living with studying in the Domicile full address country mentioned in previous column 7. a Date of birth b Present age c Age at Matriculation 8. a Place of Birth/District State in which situated b District State to which you presently belong c Distt State to which your father originally belonged 9. a Your religion b Are you a member of SC / ST / OBC strike out whichever not applicable c Name of the Caste d Category of candidature PH / EX-SM / Dependents of EX-SM killed in action 10. Educational qualification showing places of education with years in School s and Colleges s since 15th year of age. Name of School/ College Date of entrance Date of leaving Examination s passed 11. 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 or institution* If so give full particulars with dates of employment up-to- date.

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