Rank…………… CGL Exam- 2024 Annexure-A
To,
The Deputy Director,
SSS Division,
R. No 414, 4th Floor,
Ministry of Statistics and Programme Implementation,
Khurshid Lal Bhawan, Janpath,
New Delhi-110001.
Sub: Willingness or otherwise to join the Subordinate Statistical Service- reg.
Sir,
In pursuance of Letter No. 11012/1/2024- SSS dated ……….., I, hereby convey my
willingness/non-willingness* to join the Subordinate Statistical Service .
(*) strike whichever is not applicable, even if you are not interested in joining this post then also,
it is requested to convey your non-willingness to this Ministry).
Yours faithfully
Name:
Roll No:
Mob/Tele:
Email:
Place:
Date:
Rank- ....................... CGL Exam-2024 Annex.-B
District of your Present Address- ..................................
District of your Permanent Address- ..................................
ATTESTATION FORM
“WARNING”
The furnishing of false information or suppression of any factual information in
1. the Attestation From would be disqualification, and is likely to render the
candidate unfit for employment under the government.
__________________
Affix signed If detained, arrested prosecuted, bound down, fines convicted, debarred,
Passport size 2. acquitted etc. subsequent to the completion and submission of this form, the
(5 cms. X 7 cms.) details should be communicated immediately to the authorities to whom the
Approx. copy Attestation Form has been sent early, failing which it will be deemed to be a
of recent coloured suppression of factual information.
photograph
__________________ 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 services would be liable to be
terminated.
Name in full (in block letters) with
1. aliases, if any (Please indicate if you have
added or dropped at any stage, any part of
your name or surname):
2. Present Address in full (i.e. Village,
Thana and District, or House No.,
Lane/Street/Road, Town and Pin code):
3.(a) Home Address in full (i.e. Village, Thana
& District, or House No.,
Lane/Street/Road and Town, Pin Code
and name of District Headquarters)
If originally a resident of Pakistan/
(b) Bangladesh (erstwhile East Pakistan) the
address in that Country and the date of
migration to Indian Union.
4. Aadhaar Card No. (if available)
5. PAN No. (if available)
6. Nationality
7.(a) Date of Birth
Present age
(b)
(c) Age at Matriculation
8.(a) Place of birth, district and state
District and State to which you belong
(b)
District and State to which your father
(c) originally belong
9.(a) Religion
Are you a member of a Scheduled Caste/ Scheduled Tribe/ Other Backward Classes (Answer: Yes/No)
(b)
Mobile / Telephone no. - ………………………………………………… , ………………………………..………… , ………………………………………….
(in case of land-line numbers prefix the STD code also)
-2-
10. Particulars of places (with periods of residence) where you have resided for more than one year at a time during the preceeding 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 & District or House No. Lane/ Street/ Road, Name of the District
Town and Pin Code) Head Quarter or the
place mentioned in
preceding column
Occupation if Present postal address (if Permanent Home address
11. Name (in full & Nationality Place of employed give dead vive last address)
aliases, if any) (by birth & birth designation &
or by official
domicile) address
a) Father
b) Mother
c) Spouse
12. Information to be furnished with regard to son(s) and /or daughter(s) in case they are studying/living in a foreign Country:
Name Nationality Place of birth Country in which studying/ living Date from which studying/living in the
by birth or with full address country mentioned in the previous column
by domicile
-3-
13. Educational Qualification showing places of education with years in Schools and Colleges since 15th year of age:
Sr. no. Name of School/College (with full address) Date of Entering Date of Leaving Examination Passed
14. (a) 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 Designation, emoluments & Full name & address of employer Reasons for leaving previous service
From To nature of employment
14. (b) 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 month’s notice under Rule 5 of the Central Civil Services (Temporary Service) Rule 1965, or any
similar correspondence rules, were any disciplinary proceedings framed against you, or had you been called upon to explain your
conduct in any matter at the same time you gave notice of termination of service, or at a subsequent date(s), before your service
actually terminated?
-4-
15. (i) (a) Have you ever been kept under detention? Yes/No
(b) Have you ever been arrested? Yes/No
(c) Have you ever been prosecuted?
Yes/No
(i.e. has a charge sheet in a criminal case been filed against you in any court of law)
(d) Is any criminal case pending against you in any Court of Law at the time or filling up this Attestation form? Yes/No
(e) Have you ever been convicted by a court of Law for any Office? Yes/No
(f) Whether discharged/ expelled/ withdrawn from any training/ institution under the Government or otherwise? Yes/No
(g) Have you ever been rusticated by any University or any other educational authority/institution? Yes/No
(h) Have you ever been debarred / disqualified by any Public Service Commission/ Staff Selection Commission for Yes/No
any of its examinations/selection?
If the answer to any of the above mentioned question is ‘Yes’ give full particulars of the case/ arrest/ detention/ fine/ conviction/
(ii) 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:
Notes: (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. Name of two responsible person of your 1)
locality or two reference to whom you are
known:
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 and I am also liable for appropriate criminal/ civil/ legal action as a consequence.
I am not aware of any circumstances which might impair my fitness for employment under Government.
Signature of Candidate:
Date: Place :
TO BE FILLED BY THE OFFICE
i) Name, Designation and full address of the appointment authority:
Secretary
Deputy Director, (S&P.I.),
SSS Division, Room No.4 204,
Room No 414, Floor, Second Floor,
th
Ministry of Statistics and Programme Implementation,
Khurshid Lal Bhawan,
Khurshid Lal Bhawan, Janapath, NewJanpath,
Delhi – 110001.New Delhi 110001.
ii) Post for which the candidate is being considered:
Junior Statistical Officer, ‘Group – B’, Non- Gazetted
Annexure-I
DECLARATION TO BE OBTAINED FROM NEW ENTRANTS TO GOVERNMENT SERVICE
I, Shri/Smt./Kumari …………………………………………………………….…………. declare as under:
(i) That I am unmarried/ a widower/ a widow.
(ii) That I am married and have only one spouse.
(iii) That I have entered into and contracted a marriage with a person having a spouse living.
Application for grant of exemption is enclosed.
(iv)* That I have entered into and contracted a marriage with another person during the lifetime of
spouse. Application for grant of exemption is enclosed.
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:
Name:
(in Block Letters)
*Note: Please delete clause(s) not applicable.
APPLICATION FOR GRANT OF EXEMPTION
(vide para (iii)/(iv) of the declaration)
To,
The ………………………………………………
……………………………………………………..
……………………………………………………..
……………………………………………………..
Madam/ Sir,
I request that in view of the reasons stated below, I may be granted exemption from the
operation of restriction on the recruitment to service of a person having more than one wife living,
woman who is married to a person already having one wife or more living.
Reasons:………………………………………………………………………………………….……………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
Date:
Yours faithfully,
Signature:
Name:
Annex-II
UDERTAKING
I son/daughter of Sri/Smt
of village/town in District/ Division in
the State/Union Territory bearing Roll No.
of Combined Graduate Level Examination-2024 do hereby solemnly declare that I
belong to the Non-Creamy Layer category as on 24.07.2024 of the recognized
Other Backward Class (OBC)/ Economically Weaker Sections (EWS)
persons/sections as mentioned in Column 3 of the Schedule to the Government of
India, Department of Personnel & Training O.M. No.36012/ 22/93-Estt (SCT) dated
8.9.1993 which is modified vide O.M. No.36033/1/2004 Estt.(Res) dated 09.03.2004,
O.M. No.36033/3/2004-Estd (Res) dated 14.10.2008 and No.36039/1/2019-Estt
(Res) dated 31.01.2019 or the latest notification of the Government of India.
I also undertake that I fully understand the consequence that if at any stage of the
service it is found that the information furnished/declaration given by me is not true
or found false, I will be removed from the service. I shall be rendered unfit for any
Government employment and the Appointing Authority shall undertake other
criminal/ civil/ legal action, as per provisions of Indian Penal Code (IPC), etc. as
deemed fit.
Date: Candidate’s signature
Place: Candidate’s Name in block letters
