Office of the Chief Commissioner, Central Excise, Jaipur Zone, Jaipur List of candidates called for submission and chekcing of documents

Date 09.05.2016 (Monday) Time : 10 A.M.

1 SHRI SHANKEY CHUGH 19 SHRI PINKAL AGARWAL

Ward No. 20, Vikas Nagar, Sri Vijay

Nagar, Sri Ganga Nagar, Rajasthan -

335704

House No. 139, Krishna Colony, Jeoni Mandi,

Agra, Uttar Pradesh - 282004

2 SHRI PRANAV SHARMA 20 SHRI ANUJ AGGARWAL

128 Mahadev Nagar, Near Akshardham

Mandir , Vaishali Nagar, Jaipur,

Rajasthan- 302021

House No. 34, Sector 7 A Faridabad, Haryana -

121006

3 MS. PRIYA SENGAR 21 SHRI ANANT KUMAR GARG

C 4/1 EXTENSION 4 Kamruddin Nagar,

Nangloi, Delhi - 110041

67/231, Sector-6 , Pratap Nagar, Sanganer,

Jaipur - 302033

4 MS. NIDHI CHAHAR 22 SHRI AWADHESH UPADHYAY

13/123, Char Bagh, Shahganj, Agra,

Uttar Pradesh - 282001

Vill Madhwapur, Post Bargadwa, Basti , Uttar

Pradesh - 272190

5 SHRI AMIT YADAV 23 SHRI DEEPAK

J-6- PHP, Dwarka Sector 16 B Dwarka,

Delhi - 110078

Village Kisoli , Post Kisoli, Bulandshahr, Uttar

Pradesh - 203408

6 SHRI RAHUL CHOUDHARY 24 MS. PUSHPA 4/2631 OTC B-Block, Sajjan Nagar,

Sajjan Garh Main Road, Udaipur,

Rajasthan - 313001

1338 Janta Flats, GTB Enclave Near GTB

Enclave, Delhi - 110093

7 SHRI ANCHAL AGRAWAL 25 SHRI NITESH KUMAR TIWARI

Moh. Kila, Saroj Bhawan, Jalesar(ETAH)

Salesar, Uttar Pradesh - 207302

VPO-ANDHI, Teh-Jamwaramgarh, Jaipur,

Rajasthan - 303001

8 SHRI RAKESH KUMAR SHARMA 26 SHRI AJAY KUMAR 2/141 N.E.B. Housing Board, Near Manju

Hospital, Alwar, Rajasthan - 301001

H.No. 2/543, New Patel Park, Line Par, Near

New Bal Vikas High School, Bahadurgarh,

Haryana - 124507

9 SHRI DHEERENDRA KUMAR

SHARMA

27 SHRI SUMIT BISHNOI

2/28, Kala Kuan, Housing Board Alwar,

Rajasthan - 301001

House No. 3, Sector No. 3 Behind Govt. Hospital

Hanumangarh Town, Rajasthan - 335513 10 SHRI KAPTAN SINGH 28 SHRI PARDEEP KUMAR

Village Taragwan, Post Ghantry, Tehsil

Weir, Bharatpur, Rajasthan - 321409

H.No - 87 Ward No - 3 Sir Chotu Ram Colony,

Uchana, Jind, Haryana - 126115

11 SHRI KRIPA SHANKAR SINGHWAL 29 SHRI NEERAJ BHATT

VPO - Natoj, Via - Kherli, Teh-

Kathumar, Alwar, Rajasthan - 321606

C-2/239, Gali No-06, IIND Pusta, Sonia Vihar,

Delhi - 110094

12 SHRI SAHIL 30 SHRI ABHINAV SHARMA

802 Tilak Nagar, Rohtak , Haryana -

124001

D-737 Type - III Mandir Marg, New Delhi, Delhi

- 110001

13 SHRI AKHIL SHEORAN 31 SHRI RAMIT MEHLA

Quarter No. 57, G Floor, Police Station

Colony, Civil Lines, New Delhi - Delhi -

110054

H.No. 764, Sector 5 U.E. , Kurukshetra,

Haryana - 136118

14 SHRI GAURAV GOYAL 32 SHRI PRINCE KUMAR

40 A Fashion Shoes, Gali No. 2, Adarsh

Basti, Tonk Phatak Jaipur , Rajasthan -

302015

13 398, Gobind Nagar, Street No. 4, Sirsa,

Haryana - 125055

15 SHRI YOGESH SHARMA 33 SHRI AMANDEEP GAUR

H.No. 219, Durga Colony, Ward No. 13,

Hanumangarh Junction, Hanumangarh,

Rajasthan – 335512

House No. 68, Sector 3 Part 2 Huda, Rewari,

Haryana - 123401

16 SHRI KULDEEP SINGH RAJPUROHIT 34 SHRI ASHISH KUMAR SHRIVASTAVA

Rajpurohiton Ka Bass, Indira Colony

Bikaner, Rajasthan - 334001

H.No. 979/31, Phase 1, Street 1 C, Laxman

Vihar, Gurgaon, Haryana - 122001

17 SHRI MANAS UDENIA 35 SHRI MOHAN TIWARI

Markandeshwar Mandir, Near Old Subji

Mandi Palace Road, Kothi, Dholpur,

Rajasthan - 328001

H.No. 204/24, Subhash Nagar, Near C.R.A.

College Sonipat, Haryana - 131001

18 SHRI ANURAG KUMAR TRIVEDI

C/o Binod Kumar Pathak, D-310 Third

Floor , Nawada Housing Complex,

Kakrola Mode New Delhi - Delhi -

110059

Office of the Chief Commissioner, Central Excise, Jaipur Zone, Jaipur List of candidates called for submission and chekcing of documents

Date 10.05.2016 (Tuesday) Time : 10 A.M. Shri / Ms.

36 MOHIT KHURANA

54 ROHITASHWA KUMAR YADAV

H.No. 118, Bhai Parmanand Colony, Near

Mukherji Nagar, Delhi - 110009

Vill - Papra, Post - Kuhara, Teh - Viratnagar,

Jaipur, Rajasthan - 303102

37 NITIN GUPTA 55 PRADEEP BHURIA

A-3/188, Sector - 17, Rohini Delhi - 110089

190 A-1, Sunder Vihar, OPP. Power House,

Kalwar Road, Jhotwara, Jaipur - Rajasthan -

302012

38 MOHIT ARORA

56 ARMAN

B-28, Sunder Appartmens, Plot No. -13,

Sector - 14, Rohini, New Delhi, Delhi -

110085

S/o Abdul Hafiz, Nagar Panchayat-Jhanjharpur,

Ward No. 12, Near Madarsa Chowk, Distt.

Madhubani, Bihar - 847404

39 SWATI SHARMA

57 DEEPAK MAHALA

H.No. 1485/20, Hargobind Nagar, Near

Balaji Mandir, Kurukshetra, Haryana -

136118

VPO-Jankipura VIA-Jajod, Teh - Srimadhopur,

Sikar Rajasthan - 332722

40 NEPAL

58 ARUN SINGH GURJAR

VPO - Sanjarwas, Tehsil Charkhi Dadri,

Dist. Bhiwani, Haryana - 127042

Bard No. - 06, Gurjar Pada, Vill / Post - Rendayal

Gurjar , Teh-Bajeerpur, Sawai Madhopur,

Rajasthan - 322220

41 HIFZAAN KHAN 59 PRADEEP KUMAR

House No. 124,125, Block -E Madipur

Colony, Near Madipur Metro Station, West

Delhi , Delhi - 110063

Siv Colony, Nr Punam Pub School, Road No. 3,

Gudha Mode, Jhunjhunu, Rajasthan - 333001

42

ARUN SINGH

60 RAJESH ARYA

Vikram Singh Near R C Church,

Parbatpura, Ajmer, Rajasthan - 305001

S/o Prahalad Chand Arya, Ward No. 26, Colony

Badabas, Bansur Road, Kotputli, Jaipur Rajasthan

- 303108

43

SURENDRA KUMAWAT

61 UTKARSH SRIVASTAVA

104/22, Vijay Path, Mansarovar, Jaipur -

Rajasthan - 302020

A21, Rangoli Colony (Opp. New Sabji Mandi),

Sikandara , Agra, Uttar Pradesh-282007

44 ANIL KUMAR BALODIA 62 NARENDRA KUMAR

771, Sumer Nagar, Agarwal Farm,

Mansarowar, Jaipur, Rajasthan - 302020

D 190, Kolihan Nagar, Tehsil Khetri, Jhunjhunu ,

Rajasthan - 333503

45 ANIL KUMAR SAHU

63 NIRMAL CHAWLA

Indira Colony, Sawaimadhopur Road,

Apurva Collection - Tonk - Rajasthan -

304001

42 Mitra Vihar A Maharana Pratap Marg,

Panchyawala , Jaipur, Rajasthan - 302034

46 SUMIT KUMAR 64 DHANANAND TUKARAM CHANCHALKAR

House No. 107, Sarvjanik Gram Chok,

VPO- Nunia Gothara, Teh. Chirawa, Distt.

Jhunjhunu, Rajasthan - 333026

Siddharth Primary School, Nehrunagar,

Gyangboudi, Bijapur, Karnataka - 586101

47 RAJEEV RANJAN BHARTI 65 SUMIT KUMAR

S/o Ranjeet Kumar, MO - Mogalkuan Pops

- Sohshari Biharsharif , Nalanda - Bihar –

803108

H.No. 21/621 Ist Floor, Village - Karkardooma,

Delhi – 110092

48 JITENDRA KUMAR SAINI 66 GAGAN DEEP JEWARIYA

288, Main Village Bhandodi, V.P.O.

Bhandodi, VIA - Digavara, Alwar,

Rajasthan - 301414

114 Patel Nagar, Niwaru Road, Jhotwara, Jaipur,

Rajasthan - 302012

49 SUNIL KHILERI

67 PHOOL SINGH MAHAWAR

C/o Mohan Lal Khileri,Sadar Bazar,

Ladnun, Nagaur, Rajasthan - 341306

Vill-Meenapara, Post Manpur, Teh - Baswa,

Dausa, Rajasthan - 303509

50 AMIT KUMAR SONI 68 PANKAJ MEENA

Mangal Colony, Station Road,

Shrimadhopur, Distt. Sikar, Rajasthan -

332715

3/10 Ashok Vihar Colony, Narishala Road,

Subhash Nagar, Ajmer, Rajasthan - 305001

51 SANJAY KUMAR JANGID 69 LAXMI NARAYAN MEENA

Vishwakarma Bhawan, Near College Mode

Sethawali, Nathawala TH- Shahpura,

Jaipur , Rajasthan - 303103

Plot No. 1, Parwati Colony, Chetak Bhatte Ke

Samne, Goner Road, Luniyawas, Jaipur,

Rajasthan - 302031

52 NARENDRA SINGH CHAUHAN

70 KUSHAL DUBEY

A3, Shivram Colony, Near RLY Crossing,

Opp. PNB, Bank, Jagatpura - Jaipur -

Rajasthan 302017

Flat No. 18, Plot-42, Vandana Apt. Pratapganj, I.P.

Extn. Delhi - 110092

53 AWAD DAN

C/o Narayan Singh Roheria, 43, Roop

Nagar, Patoa C Road, Jodhpur -

Rajasthan - 342010

vuqizek.ku&i=

inuke % dj lgk;d

vuqizek.ku QkeZ esa dksbZ xyr lwpuk nsuk vFkok fdlh egRoiw.kZ

rF; dks Nqikuk v;ksX;rk le>h tk;sxh rFkk ;g vH;FkhZ dks ljdkjh lsok ds fy, v;ksX; djkj dj ldrh gSA ¼2½ D;k dHkh dkjkokl esa j[ks x,] U;k;ky; }kjk nks"kh fl) ik, x, vFkok fooZftr ?kksf"kr gq, gks rks mldk foLr`r fooj.k] bl QkeZ dks iw.kZ djus ds rFkk izLrqr djus ds i'pkr ml izkf/kdkjh ftlus ;g vuqizek.ku QkeZ Hkstk gS] mls 'kh?kz lwfpr dj nsuk pkfg,A lwpuk u nsus ij ;g le>k tk;sxk fd egRoiw.kZ rF; fNik;k x;k gSA

;fn fdlh O;fDr ds lsokdky ds nkSjku fdlh Hkh le; bl ckr dk irk py tkrk gS fd mlus vuqizek.ku QkeZ esa xyr lwpuk nh gS vFkok fdlh egRoiw.kZ rF; dks fNik;k gS rks mldh lsok,as lekIr dh tk ldsxhA uksV % uhps fn, x, izR;sd dkWye esa okafNr lwpuk iw.kZ :i ls fy[ksa] dksbZ Hkh dkWye [kkyh vFkok

¼&½ yxkdj u NksM+saA ¼1½ iwjk uke ¼lkQ v{kjksa esa½

¼;fn vkius dHkh fdlh le; vius uke vFkok dqyuke esa dksbZ va’k tksM+k gks vFkok mlesa ls gVk;k gks rks mldk mYys[k djsa½

%

¼2½ orZeku iwjk irk ¼ftleas xkWao] Fkkuk] ftyk] edku u0] xyh] lM+d] 'kgj rFkk ftyk eq[;ky; dk uke fn;k tk;s½

%

¼3½¼v½ LFkkbZ ?kj dk iwjk irk ¼ftleas xkWao] Fkkuk] ftyk] edku u0] xyh] lM+d] 'kgj rFkk ftyk eq[;ky; dk uke fn;k tk;s½

%

¼3½¼c½ ;fn ewy :i ls ikfdLrku ds fuoklh gSa rks ml ns'k esa mudk irk rFkk Hkkjr esa izotu dh frfFk

%

¼4½ jk"Vªh;rk % ------------------------------------------------------------------------------------- ¼5½ ¼v½ tUefrfFk % ¼c½ fnukad 01-01-2014 dks vk;q % ----------------- o"kZ ---------------- ekg ----------------- fnu

Lo;a dk gLrk{kfjr QksVks ¼ikliksVZ lkbZt½ ;gkWa fpidk;saA

¼jktif=r vf/kdkjh ls izekf.kr gks½

¼6½ xr ikWap o"kksZa esa tgkWa vkius ,d o"kZ ls vf/kd fuokl fd;k gS] ogkWa fuokl dh vof/k crkrs

gq, LFkkuksa dk fooj.k nsaA ;fn fons’k ¼ikfdLrku lfgr½ esa jgsa gksa] mu lc LFkkuksa dk fooj.k fn;k tkuk pkfg;s tgkWa vkius 21 o"kZ dh mez ds i'pkr ,d o"kZ ls vf/kd dh vof/k ds fy;s fuokl fd;k gksA

fnukad ls fnukad rd fuokl dk iwjk irk

¼vFkkZr xkWao] Fkkuk] ftyk] edku u0] xyh] lM+d] 'kgj vkfn½

fiNys dkWye esa fn, x, LFkku ds ftyk eq[;ky;

dk uke

¼7½ ikfjokfjd fooj.k % uke jk"Vªh;rk

tUe ls@ vf/kokl }kjk

dk;Z djus dk LFkku

O;olk; ¼;fn lsok esa gSa rks dk;kZy; dk irk o inuke nhft,½

orZeku Mkd dk irk ¼;fn e`r gS rks vkf[kjh irk½

¼1½ ¼2½ ¼3½ ¼4½ ¼5½ ¼1½ firk dk uke

¼miuke lfgr½

¼2½ ekrk ¼3½ iRuh@ifr ¼4½ HkkbZ

¼5½ cgusa

¼8½ ;fn iq= vkSj iqf=;kWa fons’k esa i<+ jgs gksa@jg jgsa gksa rks ml laca/k esa Hkh lwpuk izLrqr dh tk;sa % uke jk"Vªh;rk

¼tUe ls@ vf/kokl ls½

tUe LFkku iwjs irs lfgr ml ns'k dk uke tgkWa i<+ jgs gSa@jg jgsa gSaA

frfFk ftleas fiNys dkWye esa mYysf[kr ns'k esa jg@i<+ jgs gSa

¼9½ ¼v½ tUe LFkku %

ftyk rFkk jkT; ftlesa fLFkr gS %

¼c½ ftyk rFkk jkT; dk uke ftlds vki fuoklh gSa

¼l½ ml ftys rFkk jkT; dk uke % ftlesa vkids firk ewy :i ls lEc) gS

¼10½ ¼v½ /kEkZ

¼c½ D;k vki vuqlwfpr tkfr@vuqlwfpr tutkfr@ vks-ch-lh- ds lnL; gSa \ mRrj gkWa ;k uk esa nsa ;fn mRrj gkWa esa gS rks mldk uke crk;sa % gkWa@ugha -----------------------------------------------------

¼11½ 'kS{kf.kd ;ksX;rk % 15 o"kZ dh mez ds i'pkr Ldwyksa@dkWystksa esa tgkWa f’k{kk izkIr dh gS muds uke rFkk f’k{k.k o"kZ %

Ldwy dkWyst dk uke izos'k dh

frfFk NksM+us dh frfFk

mRrh.kZ dh xbZ ijh{kk

vadksa dk izfr’kr

¼12½ D;k vki fdlh dsUnzh; vFkok jkT; ljdkj vFkok v)Z ljdkjh vFkok ljdkjh o`r fudk;

vFkok fdlh Lok;Rr fudk; vFkok ifCyd v.MjVsfdax ¼lkoZtfud laxBu½ vFkok futh QeZ ;k laxBu esa fdlh in ij gSa] vFkok iwoZ esa ,sls in ij fu;qDr gq, Fks ;fn gkW rks fu;kstu dk v|ru frfFk;ksa lfgr iwjk fooj.k nhft, A

vof/k inuke] ifjyfC/k;kWa rFkk

fu;kstu dh izd`fr fu;kstu dk iwjk uke o irk

fiNyh ukSdjh NksM+us ds dkj.k

ls rd

¼13½ D;k fiNyk jkstxkj Hkkjr ljdkj@jkT; ljdkj@ljdkj }kjk fu;af=r vFkok futh

v.MjVsfdax@Lok;Rr fudk;@fo’ofo|ky;@LFkkuh; fudk; ds v/khu Fkk \ ;fn lfoZl NksM+h gS rks D;k vkius dsUnzh; flfoy lfoZl ¼vLFkkbZ lsok;sa½ fu;e 1965 ds fu;e 5 ds v/khu ,d ekg dk uksfVl fn;k Fkk vFkok blh rjg ds fu;eksa ds v/khu vkids fo:) fdlh izdkj dh vuq’kklukRed dk;Zokgh dh xbZ Fkh] vFkok lsok ls R;kxi= dk uksfVl nsrs le; vFkok okLrfod :i ls vkidh lsok;sa lekIr djus ds iwoZ vuqorhZ frfFk ij D;k vkidks fdlh Hkh ekeys esa vius vkpj.k dks Li"V djus ds fy, cqyk;k x;k Fkk \

¼14½ fuEufyf[kr izR;sd iz’u dk lqfuf’pr mRrj gkWa vFkok ugha tSlk Hkh ekeyk gks] dks iz’u ds

lkeus mYys[k djsaA ¼d½ D;k vki dHkh fxj¶rkj fd, x, gSa \ ¼[k½ D;k vkids fo:) dHkh vfHk;kstu pyk gS \ ¼x½ D;k vki dHkh utjcan fd, x, gSa \ ¼?k½ D;k vki ij dHkh U;k;ky; }kjk n.M yxk;k x;k \ ¼M-½ D;k vki dHkh u’ks esa /kqr ik, x, \ ¼p½ D;k vki dHkh fdlh U;k;ky; }kjk vijk/k ds fy, ¼fl)nks"kh½ Bgjk;s x;s \

¼N½ D;k vkidks la?k yksd lsok vk;ksx }kjk dHkh mudh ijh{kkvksa@p;uksa esa lfEefyr gksus ls vioftZr vFkok v;ksX; ?kksf"kr fd;k x;k \

¼t½ D;k vkidks fdlh ijh{kk esa csBus ls jksdk x;k vFkok fdlh fo’ofo|ky;@laLFkk }kjk fu"dkflr ¼jsLVhdsV½ fd;k x;k \

¼>½ bl vuqizek.ku QkeZ ds Hkjrs le; D;k fdlh U;k;ky; esa vkids fo:) dksbZ ekeyk cdk;k iM+k gS \

¼¥½ bl vuqizek.ku QkeZ ds Hkjrs le; D;k fdlh fo’ofo|ky; esa vFkok fdlh vU; 'kS{kf.kd izkf/kdkjh ds le{k vkids fo:) dksbZ ekeyk cdk;k iM+k gS \

;fn mijksDr iz’uksa dk mRrj gkWa esa gks rks ekeys ds fxj¶rkjh ds fo:) gksus ds@tqekZuk fd, tkus ds@dqdhZ gksus ds@n.Mkns’k fd, tkus ds@nf.Mr gksus vkfn ds iwjs fooj.k nsa vkSj@vFkok U;k;ky; esa@fo’ofo|ky; esa@’kS{kf.kd izkf/kdkjh ds le{k cdk;k iM+s ekeyksa dh izo`fr dk Hkh iw.kZ mYys[k djsaA

uksV % d`i;k bl vuqizek.ku QkeZ ds Åij nh xbZ psrkouh dks Hkh ns[ksaA ¼15½ vius bykds ds nks ftEesnkj O;fDr;ksa ds uke tks vkidks tkurs gksa % 1- ----------------------------------------------------------- 2- ----------------------------------------------------------- irk % irk % eSa izekf.kr djrk gwWa fd esjh tkudkjh vkSj fo’okl ds vuqlkj mi;qZDr lwpuk lgh vkSj iwjh gSA eq>s ,slh fdlh vkSj ckr dk Kku ugh gS tks ljdkj ds vUrxZr esjh fu;qfDr dh mi;qDrrk dks nwf"kr dj ldsaA vH;FkhZ ds gLrk{kj ----------------------------------------------- frfFk % LFkku %

¼izek.k&i= fuEufyf[kr esa ls fdlh ,d ds }kjk gLrk{kfjr fd;k tkos½ 1- dsUnz vFkok jkT; ljdkj ds jktif=r vf/kdkjhA 2- ml fo/kkulHkk {ks= ds izkFkhZ vFkok mlds ekrk&firk@laj{kd lkekU;r% jg jgk@jgsa gksa ds

fo/kkulHkk lnL; vFkok laln lnL;A 3- mi e.Myh; eftLVªsV@vf/kdkjhA 4- rglhynkj vFkok uk;c rglhynkj ftUgsa eftLVªsV dh 'kfDr;ksa ds iz;ksx ds fy, izkf/kd`r

fd;k x;k gksaA 5- tgkWa vH;FkhZ igys Nk= jg pqdk gks ,sls ekU;rk izkIr fo|ky;@egkfo|ky;@laLFkk ds

fizalhiy@iz/kkuk/;kidA 6- [k.M fodkl vf/kdkjhA 7- iksLV ekLVjA 8- iapk;r fujh{kdA izekf.kr fd;k tkrk gS fd eSa Jh@Jhefr@dqekjh -------------------------------------------------- iq=@iq=h@iRuh Jh -------------------------------------------------- dks fiNys -------------- o"kZ ------------- ekg ls tkurk gwWa rFkk muds }kjk fn, x, fooj.k esjh tkudkjh vkSj fo’okl ds vuqlkj lgh gSA LFkku % gLrk{kj % irk % ------------------------------------------------------------- uke o eqgj lfgr ------------------------------------------------------------- frfFk %

CERTIFICATE OF CHARACTER

Certified that I have known Shri ______________________________ S/o

Shri _________________________________ for the last __________ years

_________ months and that to the best of my knowledge and belief he bears

reputable character and has not antecedents which render him unsuitable for

Government Employment.

2. Shri ___________________________ is not related to me.

Place :________________ *Signature __________________

Date : _______________ Name & Designation __________

(* By a Gazetted Officer)

ATTESTED

Place :________________ **Signature : ________________

Date : _______________ Name & Designation :_______________

(Attesting Authority)

**(To be attested by Stipendiary I Class Executive Magistrate/ District Magistrate

or Sub Divisional Magistrate).

Phone No.2385021/025/007 Extn.232

FAX No. (0141) 2385222

Government of India

Ministry of Finance

Department of Revenue

OFFICE OF THE CHIEF COMMISSIONER

CENTRAL EXCISE (JAIPUR ZONE), JAIPUR (NEW CENTRAL REVENUE BUILDING, STATUE CIRCLE, C-SCHEME, JAIPUR-302005)

(CADRE CONTROL UNIT)

CANDIDATE STATEMENT AND DECLARATION CANDIDATE STATEMENT AND DECLARATION

The candidate must make the statement required below prior to his medical examination and must sign. the declaration appended thereto. His attention is specially directed to the warning contained in the note below:- 1 State Your Name in Full

(In block letters)

2 State your age and place of birth

3 a) Have you ever had smallpox, intermittent or any other fever, enlargement or suppuration of glands, spitting of blood, asthma, heart disease, lung disease fainting attacks rheumatism, append cities.

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 near relations have been affected with consumption scrofula, gout, asthma, fits, epilepsy or insanity

6 Have you suffered from any form of nervousness due to overwork or any other cause

7 Have you been examined and declared unfit for Govt. service by a Medical Officer/ Medical Board, within the last three years.

Contd. .......2/-

:: 2 ::

8 Furnish the following particulars concerning family:-

Father's age if living and state of health

Fathers age at death and cause of death

No. of brothers living their ages and state of health

No. of brothers dead their ages at death and cause of death

1 2 3 4

Mother's age if living and state of health

Mother's age at death and cause of death

No. of Sisters living their ages and state of health

No. of Sisters dead their ages at death and cause of death

5 6 7 8

I declare all the above answers to be, to the best of my belief, true and correct.

I also solemnly affirm that I have not received disability certificate/pension on account of any disease or other condition.

Candidate's signature

Signed in my presence

Signature of Medical Officer

NOTE:- The candidate shall be held responsible for the accuracy of the above

statement. By willfully suppressing any information be will incur the risk of losing the appointment and if appointed, forfeiting all claim to superannuation allowance of gratuity.

Annexure - “A”

Details of residential addresses for the last five years- S. No.

Date from Date to Complete Address of residence District Hqrs.

Signature of the candidate-------------------------------------

Name of the candidate------------------------------------------

Date------------------------------------------------------------------

Father’s name- ---------------------------------------------------

Address for correspondence----------------------------------

----------------------------------

----------------------------------

----------------------------------

Contact Phone No.-----------------------------------------------