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Verified that the applicant fulfills all eligibility criteria and facts have been tallied from his

service records. The check list below has been personally verified by the undersigned.

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(a) The Candidate’s Full Name ____________________________________. Present post of

the candidate _________________________________________ and working place of the

candidate ______________________________________________.

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(b) The Candidate’s Date of Birth, as per record is _________________. His age as on

W5I33I6W3[ is _______________ .

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Examination from ______________ University in the year ___________ .

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(d) The candidate belongs to _______________ Caste/Group/Category as per Service

record/Certificate.

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(e) The candidate has joined the Police Department on ________________. His length of

Service as ASI/HC/PC as on W5I33I6W3[is ________Years ______Months ______Days.

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For lack of records or otherwise. I am unable to verify the following.

a. T&]B/ Departmental Enquiry.

b. > \+,0G= / Involvement in Criminal Cases.

c. :` "#`'Caste/Group/Category

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Superintendent of Police/Unit Officer

(with Office Seal)

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I have read the provisions in the Notification regarding the Recruitment to the post of Inservice

Police Sub-Inspector (Civil) (Men/Women) carefully and I hereby declare to abide by the sub-rules.

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Full

Name

______________________________________

working

as__________________ and place of working ________________________________.

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My date of birth is ____________. My age as on W5I33I6W3[is _____________. It is supported

by ____________ Document.

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I am a Graduate as on W5I33I6W3[ I have passed ________________ Examination from

__________ University in ___________ Year. The supporting document is __________ .

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I belong to __________ Caste/Group/Category. The supporting document is __________ .

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I joined the Police Department on ________________. My length of Service as on W5I33I6W3[

is _______________ years __________ months _________ days.

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I declare that I have neither been involved in any Criminal case nor any Departmental Enquiry

is pending against me.

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I hereby declare that the above information is true. I am aware that I am liable for action

against me in the event of any information being found false or incorrect or ineligibility being detected

before, during or after the examination/interview/appointment.

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I further declare that I have not been debarred from appearing for any similar examination.

Date/("a

>i\Dl"#RN

Place/ ha

Signature of the candidate

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