ANNEXURE
ATTESTATION FORM
,,WARNING"
1 The furnishing of false information of suppression of
any factual information in the Attestation Form would
be d isq ua lification and is likely to render the
candidate unfit for employment under the
Affix Signed Government.
I Passport Size
(5cms.X7cms.) 2 lf detained, arrested prosecuted, bound down fines
Approx Copy - 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 of which it will be deemed to be a
suppression of factual information.
I
3 lf, the fact that false information has been furnished
or that there has been suppression or 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.
L Name in full (ln block capitals) with Surname Na me
aliases, if any. (Please indicate if
you have added or dropped in any
stage, any part of your name or
surna me):
2. Present Address infull (i.e. Village,
I
Thana and District or House No.,
I Land/Street/Road & Town):
3.(a) Home Address in full (i.e. Village,
Thana and District or House No.,
Land/Street/Road & Town and
name of District Headquarters):
I
lf originally a resident of
(b) Pakistan/Bangladesh (erstwhile
East Pakistan) the address in that
country and the date of migration
to lndian Urban.
4 Aadhar Card No. (lf available)
5 PAN No. (lf ava ila ble)
6 Nationa lity
7 .(al Date of Birth
(b) Present aBe
I
(c) Age of Matriculation
Page-l of 4
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 I
originally belong
e.(a) Your Religion
(b) Are you a member of a scheduled
Caste/Scheduled Tribe/Other Backward
I
Classes? (Answer Yes/No
10. Particulars of places (with periods of residence) where you have resided for more than one
year at a time during the preceding five years. ln case of itay 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 tven
From To Residential Address in full Name of the District Headquarter of the place
(i.e. Village, Thana & District mentioned in preceding column.
of House No. I
I
Lane/Street/Road & Town
11. Name (in full Nationality Occupation if Present Permanent
address if any) (by birth & or Place of birth employed give Postal Home
by domicile designation & Address (if Address
officialaddress dead vive
la st
address
a)Father
b)Mother
c) Spouse
12. n t o rm .l t o n t o be f u n s h e d th reg a r d t o S o n s a nd o r d a U h te r s n c a S e h ey a e
S Ud n n n a fo re n CO unt
Name Nationality by Place of birth Cou ntry in which Date from which studying/living in
birth & or by studying/living the country mentioned in the I
domicile with full address previo us column
Page-2 of 2
13. Educational Qualification showing places of education with years in Schools and Colleges since
L5th ar of age:
Name of School/College (with full Date of entering Date of leaving Exa mination passed
address):
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 lnstitution? (so, give full particulars with date of employment up-
to-date.
Pe riod Designation, emoluments & Full name & address Reasons for leaving
nature of employment of employer previous Service
From To
14. (b) lf the previous' employment was under the Government of lndia/a State
Government/underta king owned or controlled by the Government of lndia or a State
Government/and Autonomous Body/University Local Body.
lf you had left service on giving a month's notice under Rule 5 of the Central Civil Services
(Temporary Service) Rules 1965 or any similar correspondlng 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?
1s. (i) (a) Have you ever been kept under detention? Yes/No
(b) Have ou ever been arrested? Yes/No
(c) Have you ever been prosecuted? (i.e. has a Charge Sheet in a Criminal Case been Yes/No
filed against you in any Court of Law)
(d) ls any criminal case pending against you in any Court of Law at the time of filling Yes/No
I
up this Attestation Form? I
(e) Have you ever been convicted by a Court of Law for any Office? Yes/No
(f) Whether disch?rged/expelled/withdrawn from any train ing/institution under the Yes/No
Government or otherwise?
(e) Have you ever been rusticated by any University or any other educational Yes/No
authority/institution?
{h) Have you ever been debarred/disqualified by any Public Service Yes/No
commission/Staff Selection Commission for any of its examination/selection? I
(ii) lf the answer to any of the above mentioned question is 'Yes' give full particulars of the
case/arrest/detention/line/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:
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 shirking out 'Yes' or 'No' as
the case may be
Page-3 of 3
(1)
16. Names, address & aadhar num ber of two
responsible person of your locality or two
references to whom You are known:
l2l
DECLARATION
l 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 any appointment letter and I am also liable for
appropriate CriminaUCivil/Legal action as a consequence.
I am not aware or any circumstances which might impair my fitness for employment under Government.
Signature of Candidate
I
I
I Date:
Place:
INDEMNITY CERTIFICATE
Certificate to be signed by any one of the following:-
(i) Gazetted Officers of Central or State Governmenu
(ii) Members of Parliament of State Legislature belonging to the constituency where the
candidate or his Parent/guardian is ordinarily resident;
(iii) Sub-DivisionalMagistrates/Officers;
(iv) Tehsildars or Naib/Deputy Tehsildars authorized to exercise magisterial powers;
(v) Principal/Headmasters of the recognized School/College/lnstitution where the candidate
studied last;
(vi) Block Development Officers;
(vii) Panchayatlnspectors;
Certified that I have kriown Shri/Smt/Kumari
son/daughter of Shri ...... .......................... for the last Yea rs ..........
months and that to the best of my knowledge and belief the particulars furnished by him/her are
correct.
Date : ........................
Place:.
(i) Name, Designation and full address of the appointment authority
(ii) Post for which the candidate is being considered.
Page-4 of 4
ANNEXURE.I
AFFIDAVIT FORMAT
(Before 1"t Class Executive Magistrate)
t, ....... s/o
Date of bifth Relig ion
residing at village Post
.... Police station ..... . District ... ..
Pin code .. State .. . .. is being appointed to the Post of
Junior Engineer/Mechanical/Design Drawing and Estimation, Cat-17A in Jamalpur
Workshop in Pay Level - 06 (7th CPC) against RRB/Kolkata CEN No. 0312024
provisionally pending detailed verification for character and antecedents. I have
submitted a Character Certificate from Head of educational lnstitution I last
attendediGazetted Officer (delete whichever is not applicable) for verification of my
character and antecedents. I hereby certify that I have no adverse report with the Police
authorities anywhere in lndia or abroad and have no criminal case/pending against me
nor I have convicted in any Criminal case in the past.
ln case of any adverse report about my charactered antecedents is later given by
the Civil authorities, the administration of Eastern Railway will be well within their rights
to terminate my service and cancel my candidature for the post of Junior
Engineer/Mechanical/Design Drawing and Estimation, Cat-17A Level- 06 forthwith
without any notice.
Signature and name of the Candidate
Full Address:-
ANNEXURE - II
CHARACTER CERTIFICATE
(To be signed by a Gazetted Officer)
Certified that I know Sri/Smt./Kumari
having date of Bi(h and S/o/WoSri/Late
for the last ......... years months and that to the best of my knowledge
and belief he/she bears reputable character and has no antecedents which
render him unsuitable for Government employment.
Sri/Smt./Kumari is not related to me.
Place Signature (with office seal)..............
Date Name
Designation
ANNEXURE - II
CHARACTER CERTIFICATE
(To be signed by a Gazetted Officer)
Certified that I know Sri/Smt./Kumari
having date of Birth and S/oM/o Sri/Late
for the last ......... years months and that to the best of my knowledge
and belief he/she bears reputable character and has no antecedents which
render him unsuitable for Government employment.
Sri/Smt./Kumari is not related to me.
Place Signature (with office seal)
Date Name
Designation
ANNEXURE _ III
CERTIFICATE OF CHARACTER
To be obtaine form the Head of lns tution where the candidate studied last
Certified that I
have known Sri/Smt.
having date of 8irth.....................S/o Sri
for the last years Months and that to the best of my knowledge
and belief he/she bears reputable character and has no antecedents which
render him unsuitable for Government employment.
Sri/Smt is not related to me.
Place Sig natu re
Date Date
"(To be attested by Stipendiary 1"t Class Executive Magistrate, District
Magistrate or Sub- Divisional Magistrate / S.D.O)"
Attested
S ig natu re
Designation
estin Authori
.(This should be done after the candidate
has been finally selected for appointment)
ANNEXURE _ IV
DEC I"ARATION OFC CTE R AND ANTE CEDENTS
PRIOR TO PROVIS IONAL APPOINTM ENT IN
GO VE RNMENT SE RVICES: -
I, Son/wife of Late
hereby
declare that the facts Biven in 12 (il and tZ (iil in attestation form by me are
correct and if any false information/facts herein mentioned are found to be
incorrect or false at a future date, my services may be terminated.
This is also certified that no any adverse Police Cases are pending
against me in any Police Station.
Name
Father/Husband Name:
Address
Mobile Number
Sisnature of the Ca ndidate
DEED OF INDEMNITY
SPECIAT ADHESIVE STAMP
BEFORE FILTING THE FORM
The Deed of indemnity made this .............day of ...........2025 by Sri ....................
. son of Sri/Late ...............residin9
at.
(Hereinafter referred to as'TRAINEE'which expression shall include his heirs, executors, administrators and
representatives where the context so admits) and Sri/Smt
Son of Sri/1ate............................1...... residing at..
Hereinafter referred to as
'surety'which expression shall include his heirs, executors, administrators of Eastern Railway (hereinafter
referred to as THE GOVERNMENT) of the OTHER PART
WHEREAS the government has engaged the trainee on the terms and conditions mentioned in the joining
report dated....................... executed by and between the Trainee and the Government.
AND WHEREAS the surety is interested in the welfare of the said trainee and therefore has agreed to these
present as a Surety.
AND WHEREAS one of the terms and conditions to the said engagement of the Trainee is that the trainee
shall complete the prescribed training and after such completion shall accept service under the
government and serve the Government for a minimum period of 05(Five) years and if the trainee desires
to serve or resigns from the service during the period of training or thereafter without the written consent
of the Government or is discharge there from for misconduct or any other offence, the trainee shall repay
on demand by the government the whole cost of training plus 1.2.5% interest any other amounts, excluding
Travelling and running allowahce drawn by the trainee from the Government under these terms and
conditions.
AND WHEREAS THE SURETY has agreed to indemnity and/or to reimburse to Government to that extent.
NoW THESE PRESENTS WITNESS and it is hereby agreed by and between the parties as follows:-
1. That in consideration of the premises and in consideration of the Government agreeing to engage
the trainee for the course mentioned in the joining report referred to above, the trainee after
completing the training satisfactorily, shall serve the Government for a minimum period of five
years thereafter in accordance with the said joining report executed between the Trainee and the
Government to the complete satisfaction of the Government. (Decision of the Government about
which shall be final and conclusive).
2. That the Trainee and the Surety hereby undertake jolntly and severely to indemnity and reimburse
the Government to that extent as aforesaid.
3. That in the event of Trainee getting adverse report regarding the progress of his training, of studies
or conduct or on discontinuing his studies or being discharged from the course or on refusal to
continue for any reasons not beyond the control of the trainee or doses not continue in service as
aforesaid, the trainee and the surety shall jointly and severely be liable to pay and refund forthwith
to the Government on demand and without demur in cash all money expended.
Signature of the Trainee Signature of the Surety
On the Trainee or on his account in respect of his training course as stated above and the declsion of
the Government as to the amount so payable shall be final together with interest on the said moneys
calculated at the rate then in force for Government loans.
Paqe-(2)
4. That the liability of the Surety hereunder shall not be impaired or discharged by reason of time
being grant or any for biarance act or omission of the Government or any person authorized by the
Government (whether with or without the knowledge of the Surety), nor shall it be necessary for
the Government to sue the trainee before suing the Surety for the amount due hereunder:-
5. That if there is any dispute as to the effect or meaning of these presents or otherwise, however,
except as to matters for which specific provision has been made in these presents, the same shall be
referred to the sole arbitration of the Secretary to Government of lndia in the Ministry of Railways
or any person appointed by him whose decision shall be final and binding on the parties. The
provisions of lndian Arbitration Act 1940, as amended from time to time shall apply.
lN WITNESS THERE OF, the parties have set their hands on the day and year first mentioned above.
WITNESS FOR TRAINEE TRAINEE
1. Signature Signature
Name and Address Name
Date Date
2. Signature
Name and Address
Date
WITNESS FOR SURETY 5U RETY
1. Signature: Signature
Name : Name and Address
Address Office and Place
2. Signature :
Name :
Address :
CE RTIFICATE REGAR OING PAY OF SURETY
This is to certify that the gross salary of Sri/Smt Who is
working as .in the office of ......... is
Rs
Signature :
OFFICE SEAL Designation:
Date :
(To be signed by the pay Drawing Officer)