Combined Graduate Level Examination, 2021 – Pre-Appointment Formalities for Assistant Section Officers

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Successful candidates nominated for the Assistant Section Officers’ Grade of CSS (Central Secretariat Service) are required to complete pre-appointment formalities through an online portal. This includes filling up/uploading willingness forms, attestation forms, and medical fitness certificates. Candidates residing in Delhi have additional requirements for police verification. Medical examinations are mandatory for all candidates, with specific instructions provided for those residing in and outside Delhi. Candidates should submit all necessary documents by April 25th, 2023, and are advised to regularly check the DoPT website for updates. The document also outlines conditions regarding candidates’ certificates being found fake or submitting false information.

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F.No.7/10/2023-CS.I(A)
Government of India
Ministry of Personnel, Public Grievances \& Pensions
(Department of Personnel \& Training)
CS.I Division

$2^{\text {nd }}$ Floor, Lok Nayak Bhawan, Khan Market, New Delhi -110003.

Dated the $10^{\text {th }}$ April, 2023.
To
The Successful candidates of CGLE, 2021
Nominated to Assistant Section Officers’
Grade of CSS (as per Annexure-I)
Subject: Combined Graduate Level Examination, 2021 – Intimation regarding preappointment formalities for the post of Assistant Section Officers’ (ASO) Grade (Group B, Non-Gazetted) of Central Secretariat Service (CSS).

Dear Candidates,

Congratulations on your success in the Combined Graduate Level Examination, 2021!

I am directed to say that you have been allocated and nominated for appointment to Assistant Section Officers’ Grade of Central Secretariat Service by Staff Selection Commission on the basis of Combined Graduate Level Examination (CGLE), 2021 as per the list attached. The allocation has been made on the basis of your rank in the merit list, eligibility, preference for services expressed by you and availability of vacancy. Though utmost care has been taken while preparing the list annexed, yet you are advised to cross check the particulars pertaining to yourself with the result declared by SSC and report discrepancies, if any.
2. All the successful candidates nominated for the Assistant Section Officers’ Grade of CSS are pre-registered on the Online Portal https://doptapp.nic.in/CGLE/ASO. The candidates are required to fill-up/upload and submit the following documents online:
(i) Willingness to join the post.
(ii) Attestation Form (AF)
(iii) Medical Fitness Certificate
2.1 The candidates, who are presently residing in Delhi or those who indicate having resided in Delhi in the point number 10 of the AF should additionally fill the “Delhi Police Verification Form” given in the portal. The detailed guidelines for filling up/uploading of the aforesaid forms through the Portal are given in Annexure-II.
3. All the candidates residing outside Delhi are required to appear before the Civil Surgeon/Principal Medical Officer/Chief Medical Officer of the District where the candidates are presently residing, for medical examination, to determine their fitness for the Government service. The candidates are required to give a statement and declaration regarding his/her health in the attached form in the presence of Medical Officer. The medical certificate of fitness should be in the prescribed format, a specimen of which is attached as Annexure-III. The Authorities concerned are also requested to take up the Medical Examination of the candidates concerned on the strength of this letter. In case any other authority letter is required by the Office of medical authority concerned, the undersigned may be contacted through mail at cs1-a-dopt@gov.in. The candidates must send the Original Medical Certificate to the undersigned by speed post/registered post within the specified period.


3.1 Candidates presently residing in Delhi, as per the information furnished in their Application form submitted to SSC, will be informed about their medical examination through the online portal.
3.2 However, if the candidate is already in Government service, instead of obtaining a fresh medical report, they may produce this letter to their Controlling Authority to enable them to forward an attested copy of their medical examination report (with attested photograph) obtained at the time of the appointment, to the undersigned. The candidates must ensure that the said medical examination report furnished to the previous employer should have been issued by Civil Surgeon/Chief Medical Officer or equivalent.
3.3 Further, candidates residing outside Delhi who wish to get their medical examination conducted in Delhi, may opt for the same in the willingness form. However, it may be noted that no TA/DA will be provided by the Department in such cases. Further, they will have to undergo their Medical Examination on allotted date and time.
4. Candidates should ensure that the requisite documents/information as sought vide paras above, are submitted/uploaded on the online portal latest by $25^{\text {th }}$ April, 2023. In case of any query, candidates may contact the undersigned.

The Under Secretary CS.I (A)
CS.I Division,
Department of Personnel \& Training,
$2^{\text {nd }}$ Floor, Lok Nayak Bhawan,
Khan Market, New Delhi-110003
Tel: 011-24642705
Email: cs1-a-dopt@gov.in
5. It may also be noted that mere submission of willingness and other documents will not entitle any candidate to claim appointment to the post which will be subject to the fulfilment of stipulated terms and conditions.
6. The eligibility of candidates shall be determined for consideration for appointment based on the information furnished in the attestation form. If found eligible, candidates will be offered appointment to the post of Assistant Section Officer in Central Secretariat Service subject to the verification of character and antecedents/claim for EWS/OBC (Non-creamy layer)/SC/ST/PwBD status. The formal offer of appointment will be sent to you separately by this Department.
7. The candidates will have to undergo the foundation course organized by the Institute of Secretariat Training and Management (ISTM) or any other Institute(s) nominated for this purpose, as and when organized. The Foundation Course is compulsory and has to be completed as a part of the successful completion of probation in service.
8. The candidates must note that in case, at any stage, it is found that the candidate’s certificate is fake or candidate has furnished false information, he/she shall be liable to be proceeded against, under the relevant rules, leading to such penalty as may be decided, which now extends to the termination of his/her appointment. Such action shall also be without prejudice to any other punitive action as may be attracted in such cases.
9. Attention is also invited to this Department’s OM No. 11012/7/91-Estt.(A) dated 19.05.1993 as amended from time to time which already stipulates the action that can follow on furnishing of false information or submission of false certificates. The operative part of the said OM is reproduced below:-


“Wherever it is found that a candidate who was not qualified or eligible in terms of the recruitment rules etc. for initial recruitment in service or had furnished false information or produced a false certificate in order to secure appointment, he should not be retained in service. If, he is probationer or a temporary Government servant, he should be discharged or his services should be terminated. If he has become a permanent Government servant, an enquiry as prescribed in Rule 14 of CCS (CCA) Rules, 1965 may be held and if the charges are proved, the Government servant should be removed or dismissed from service. In no circumstances should any other penalty be imposed”
10. The offer of appointment when made, will be provisional for the candidates who have claimed/availed the benefits of any type of reservation for posts and service in terms of the following instructions as may be relevant to them:-
(i) EWS Candidates:- The appointment is provisional and is subject to the due verification of Income and asset certificate by DoP\&T.
(ii) SC/ST Candidates: – The appointment will be provisional and is subject to due verification of SC/ST certificate by DoP\&T.
(iii) OBC Candidates:- This Department has issued OM No. 36012/22/93Estt.(SCT) dated $8^{\text {th }}$ September, 1993; OM No. 36033/3/2004-Estt.(Res) dated $14^{\text {th }}$ October, 2008 and other extant instructions in this regard from time to time. In accordance with these instructions, only Non-Creamy Layer OBC candidates are entitled to get the benefits of reservations earmarked for Other Backward Classes (OBC). The allocation is, therefore, provisional to this extent and is subject to further verification of OBC certificate by DoP\&T
(iv) PwBD Candidates:- The appointment will be provisional and subject to due verification of concerned certificate by DoP\&T.

Yours faithfully,
(George D. Toppo)
Under Secretary to the Government of India
Tel: 24642705
NOTE: 1. Candidates may please note that further updates/information with regard to appointment to the post of ASO on the basis of CGLE-2021 will be provided only on the website of DoP\&T (www.dopt.gov.in-What’s new) and also www.dopt.gov.in – About us Central Secretariat – Central Secretariat Service – Recruitment (DR Assistants). They are, therefore, advised to regularly visit DoP\&T’s website for any updates.
2. Candidates should indicate their All India Rank of CGLE 2021 in all their correspondence with this Department, including in the subject of email.


Annexure – I

SNO SALUTATION NAME RANK DOB
1 SHRI RISHABH KUMAR 1 21-01-01
2 SHRI RAJAT SINGH 39 13-10-94
3 SHRI BASUDEV YADAV 50 08-07-00
4 SHRI RUKMESH 61 25-09-99
5 SHRI AMAN DEEP 100 13-10-96
6 SHRI MAYANK AGRAWAL 101 14-10-99
7 SHRI BHANU PARTAP 104 12-06-98
8 MS SHIKHA CHAMOLI 118 14-08-00
9 SHRI HARIOM SINGH 120 11-07-00
10 SHRI PRANJAL 121 21-03-98
11 SHRI RISHABH GUPTA 125 05-07-00
12 SHRI NEETAN 130 04-10-98
13 SHRI HIMANSHU SAINI 131 03-07-99
14 SHRI ARYAMA YUGANKAR 136 01-05-95
15 SHRI NITIN BARGALI 150 23-03-01
16 SHRI ASHISH BIRHMAN 155 25-06-01
17 SHRI ROHIT MALIK 158 05-06-93
18 SHRI ABHISHEK KUMAR SINGH 159 06-06-92
19 SHRI RAVI DUTT 162 12-11-00
20 SHRI MOHAN SINGH 175 12-12-95
21 SHRI RAHUL DOBHAL 176 12-04-98
22 SHRI ANTRIKSH TEOTIA 177 11-10-98
23 SHRI JATIN KUMAR VARSHNEY 179 13-05-01
24 MS AASHIMA 180 08-08-96
25 SHRI HARSH BISHT 183 15-07-99
26 SHRI PAWAN PANDAY 187 11-06-96
27 MS MAYUKHI BHOWMICK 190 01-12-99
28 SHRI TUSHAR RAJ 191 04-05-01
29 SHRI AMIT BOHRA 194 05-08-99
30 SHRI AMAN KUMAR 195 28-01-95
31 MS SANGEET KAUR SALUJA 200 03-07-96
32 SHRI NAKUL SHARMA 205 05-07-92
33 SHRI MOHIT AGRAWAL 212 01-01-98
34 SHRI AKASH SINGH 223 16-08-99
35 SHRI VINAYAK TIWARI 227 15-06-97
36 MS JASPREET JAGGI 230 17-03-97
37 SHRI NARENDRA SINGH 234 05-06-95
38 SHRI VIVEK TIWARI 239 12-08-93
39 MS MONIKA 240 14-10-97
40 SHRI MANSSIJ BALYAN 246 30-03-96
41 SHRI SUDARSHAN SINGH 248 05-07-97
42 SHRI ALOK NEGI 251 11-02-00
43 SHRI YOGESH CHAUHAN 263 22-02-94
44 SHRI UMESH BUGALIA 267 14-06-97
45 MS SOUMYA AGARWAL 270 12-03-98
46 SHRI RISHABH PRATAP SINGH BHADAURIY 274 15-07-96
47 SHRI NIRBHAY GUPTA 277 10-05-98
48 SHRI FIROJ KHAN 286 12-07-99
49 SHRI RAJAT PRATAP SINGH 287 21-09-92
50 SHRI ABHISHEK MISHRA 296 13-03-94
51 SHRI DINKAR CHOUDHARY 297 01-01-99

SNO SALUTATION NAME RANK DOB
52 SHRI SHASHI KUMAR 301 02-10-96
53 SHRI ABHIJEET CHAUDHARY 305 20-03-98
54 SHRI MUKUL RAJ 309 05-02-99
55 SHRI AMIT KUMAR SINGH 310 19-09-95
56 SHRI SOUVICK DAS 311 05-09-93
57 SHRI PARV SHARMA 312 28-10-97
58 SHRI SHREY TIWARI 314 30-04-98
59 SHRI ABHISHEK OJHA 317 26-12-94
60 SHRI NITIN KUMAR 323 25-08-94
61 SHRI AMAN KUMAR 324 23-12-99
62 SHRI RAUNAK SHARMA 329 20-03-96
63 MS ANJALI 339 12-05-93
64 SHRI MO KASHIF ANSARI 341 17-07-99
65 SHRI JAIDEEP 342 07-01-01
66 SHRI ROBIN 343 10-03-95
67 SHRI AKASH JOON 347 15-04-99
68 SHRI HIMANSHU 350 20-06-96
69 SHRI MADHAV BHADORIYA 351 31-12-95
70 SHRI TABISH JAMAL 353 27-06-95
71 SHRI RATNAKAR SHARMA 354 17-06-97
72 SHRI MOHIT RAWAT 357 14-07-92
73 SHRI SANYAM KHANNA 371 25-01-99
74 SHRI SNEH PRATIK 375 08-11-98
75 SHRI SHUBHAM KUMAR SINGH 377 13-08-97
76 SHRI SUMIT KUMAR 378 01-01-96
77 SHRI RAM BHAWAN 379 27-02-95
78 SHRI ROHIT KAUSHIK 380 04-06-98
79 MS UPASANA CHAUHAN 381 27-10-99
80 SHRI PRATEEK JAIN 382 03-07-99
81 MS NANDINI GUPTA 386 10-01-95
82 SHRI SAHIL RANA 389 20-06-98
83 MS SHIKHA PATHAK 391 25-11-95
84 SHRI ANKIT SHARMA 418 29-07-99
85 SHRI BAMBAM KUMAR 428 07-01-99
86 MS MANISHA SAHNI 429 29-01-94
87 MS SHEELU YADAV 434 01-03-97
88 SHRI AVIKAL KUMAR 453 15-02-96
89 MS KAVITA KUMARI 462 16-11-97
90 SHRI SUSHIL SINGH 465 03-06-00
91 MS GARIMA VERMA 476 19-12-97
92 SHRI SHUBHAM SAINI 486 06-10-95
93 SHRI SAURAV SINGH TOMAR 487 10-09-96
94 SHRI ALOK PANDEY 496 20-10-95
95 SHRI AYUSH GOYAL 502 31-12-96
96 SHRI KAUSHAL CHAND 515 24-06-98
97 MS ANTIM 527 02-08-00
98 SHRI AKASH YADAV 547 02-09-00
99 SHRI PRASHANT MAURYA 570 06-08-99
100 SHRI MUKUL 572 10-05-97
101 SHRI ROHIT YADAV 575 14-02-01
102 SHRI SHAHNAWAZ ALI 577 30-06-95

SNO SALUTATION NAME RANK DOB
103 SHRI SUBHASH 593 02-12-96
104 SHRI MAYANK GUPTA 599 15-08-00
105 SHRI SUNIL KUMAR PAL 600 07-07-91
106 SHRI AYUSH VERMA 611 13-05-99
107 SHRI PALAK KUMAR PANDEY 616 24-04-99
108 MS PRIYA VERMA 624 02-10-97
109 SHRI ANKUR SARASWAT 627 29-11-01
110 MS MEGHA BANSAL 628 24-09-92
111 SHRI ANKIT MISHRA 633 01-07-95
112 SHRI DEPENDER SINGH RATHORE 637 22-01-00
113 SHRI PRAVEEN KUMAR 641 25-08-98
114 SHRI ASHISH GUPTA 648 24-09-94
115 SHRI AMIT 650 04-03-98
116 SHRI RAJEEV RAJ GUPTA 652 12-05-97
117 SHRI DEEPANSHU CHHOKKAR 665 10-01-99
118 SHRI RAJAT YADAV 677 28-02-97
119 SHRI SATYAM KUMAR 716 28-02-98
120 SHRI NISHIT INDORA 728 02-12-97
121 SHRI SHIV SHANKAR PAL 748 20-11-99
122 SHRI AJAY KUMAR 753 03-02-93
123 SHRI RAKESH PRAJAPAT 764 02-08-97
124 SHRI MANOJ KUMAR VERMA 782 05-06-95
125 SHRI VIKAS SHEORAN 795 23-05-95
126 SHRI KAPIL 805 25-06-99
127 SHRI KUNAL BANSAL 808 24-06-01
128 SHRI PRADHUMN SINGH 809 14-03-99
129 SHRI SUDHANSHU KUMAR 812 22-08-00
130 SHRI SOHAIL RASOOL 815 10-11-95
131 SHRI JAIPAL SINGH 827 13-03-99
132 MS RASHMI CHAUDHARY 834 17-05-99
133 SHRI VISHWAJEET KUMAR SINGH 845 04-12-98
134 SHRI SANTOSH KUMAR SAINI 853 17-04-01
135 SHRI RAHUL YADAV 863 20-06-94
136 SHRI AMIT KUMAR 883 30-08-98
137 SHRI AJAY KUMAR 890 03-12-98
138 SHRI RAJAT JANGID 903 20-10-98
139 MS YACHNA KUMARI 904 05-10-89
140 SHRI KAPIL YADAV 911 09-11-98
141 SHRI TARUN KUMAR 928 19-03-99
142 SHRI UJJWAL KATIYAR 956 01-10-93
143 SHRI UJJWAL KUMAR 963 15-01-99
144 MS ANJANA KAUSHAL 969 08-11-96
145 SHRI NARESH PRASAD MAHATO 973 03-03-94
146 SHRI ANIKET YADAV 990 21-11-00
147 SHRI BRIJESH 1011 05-05-00
148 MS SHALINI VERMA 1018 04-12-00
149 SHRI DEEPENDRA KUMAR 1025 21-07-99
150 SHRI AVINASH 1040 10-12-93
151 SHRI ABHISHEK KUMAR DHAKER 1071 02-10-92
152 SHRI SHIVANSHU KUMAR 1077 20-08-99
153 SHRI RAJU JANGID 1079 17-08-00

SNO SALUTATION NAME RANK DOB
154 MS KOMAL YADAV 1110 23-08-99
155 SHRI PAWAN KUMAR 1118 13-07-96
156 SHRI ARUN KUMAR 1123 12-02-98
157 SHRI ASWINI KUMAR GUPTA 1130 13-01-98
158 SHRI ROSHAN KUMAR 1131 30-06-95
159 MS BHUMIKA 1136 11-02-98
160 MS CHAILSI 1309 25-08-01
161 SHRI VISHAL 1715 03-10-98
162 SHRI ARDHENDU MANI TRIPATHI 1926 14-06-95
163 SHRI SANJAY KUMAR ROUT 2185 23-09-94
164 SHRI VINOD KUMAR 2470 18-03-97
165 SHRI RAHUL KUMAR 2511 15-04-01
166 MS MADHULIKA RAJ 2598 13-07-96
167 SHRI SHUBHAM VED 2734 26-12-99
168 SHRI ABHISHEK BHARTI 2851 05-11-00
169 SHRI AMIT KUMAR 2880 14-05-00
170 MS PRIYANKA 2884 16-04-01
171 MS ANKITA RAJ 2903 20-03-96
172 SHRI SHIVAM KOTIA 3157 16-10-98
173 SHRI ANSHUMAAN YOGI 3198 25-11-98
174 MS SHWETA SINGH 3351 27-06-96
175 SHRI ANIL KUMAR SINGH 3436 09-08-99
176 SHRI PRASHANT SINGH 3474 01-08-95
177 SHRI THEMASKAR CHETAN BABUJI 3497 29-06-94
178 SHRI VIMAL KAMAL 3521 08-01-97
179 SHRI AMAN KUMAR 3549 20-04-94
180 SHRI PARAMJEET SINGH 3567 11-08-94
181 SHRI DHEERAJ MAHAWAR 3601 05-07-99
182 MS PRERNA SINGH 3620 09-02-96
183 SHRI PARIKSHIT SINGH 3640 27-10-98
184 SHRI LALIT KUMAR MEENA 3889 01-09-94
185 MS SUNYANA MEENA 4038 15-07-94
186 SHRI VIJAY PANWAR 4085 02-12-96
187 SHRI HEMANT KUMAR MEENA 4317 20-01-01
188 MS KAJOL MEENA 4334 26-10-99
189 SHRI VIKAS KUMAR MEENA 4338 10-08-96
190 SHRI SANJAY MEENA 4353 11-02-96
191 MS NITIKA MEENA 4356 17-12-95
192 SHRI DEVENDRA KUMAR MEENA 4364 16-07-98
193 SHRI RAJIV PURI 4374 18-12-99
194 MS KUSUM MEENA 4397 22-02-94
195 SHRI NARENDER KUMAR MEENA 4417 26-01-95
196 SHRI SANJEEV KUMAR MEENA 4426 10-09-00
197 SHRI INDERJEET SINGH RAWAT 4446 01-01-92
198 SHRI RAM SINGH MEENA 4465 06-07-94
199 SHRI RAVI KUMAR KHARWAR 4487 31-07-94
200 SHRI TANUJ KUMAR 4905 29-09-92
201 SHRI MOHAK RAJPAL 5795 04-12-96
202 SHRI MUKHTAR KHAN 6161 05-03-95
203 SHRI VIMAL SHARMA 6191 11-03-93

Annexure-II

Guidelines for completion of pre-appointment formalities to the post of ASO in CSS selected on the basis of CGLE-2021 on Online Portal (https://doptapp.nic.in/CGLE/ASO).

Note: Candidates are advised to read the following instructions before completion of pre-appointment formalities and should keep the soft copies of the following handy:

  • Passport size photograph (max 50KB/JPG format)
  • Signature (max 20KB/JPG format)
  • Photo Identity [PAN/VoterID/Driving Licence/Aadhaar] (max 100KB/JPG or PDF format)
  • Address Proof [Passport/Telephone/Electricity/PNG bill/Aadhaar Card/Voter ID/Bank Passbook/Rent Agreement] (max 100KB/JPG or PDF format)
  1. It may be noted that candidates who have been selected for the post of ASO in CSS on the basis of CGLE-2021 are pre-registered with basic details (like-Name, Roll No. Rank, Category, DoB, Mobile Number, e-mail id) on the Online Portal.

  2. Candidate should click on FORGOT password to create a new password through their e-Mail id and mobile number furnished to SSC while applying for the post.

1
2
3

Pre-appointment formalities for the posts of Direct Recruit (DR) Assistant Section Officer (ASO) in Central Secretariat Service(CSS).

1
2 |
3 |

In the next screen that follows, the email address and the mobile number (provided to SSC at the time of application) should be entered. Separate OTPs will be sent to the Email & Mobile which should be entered at appropriate boxes. Please follow online instructions and complete the registration. After completing the registration, the candidates can login using the email address and the password set by them and update their profile.

  1. Candidates must fill up and submit the following documents through the Online Portal:

i) Willingness Form

ii) Attestation Form


iii) Delhi Police Verification Format – This Police Verification form will be available to those candidates who have declared themselves as resident of Delhi in the willingness form and/or have filled a Delhi address in the residential history of the Attestation Form.

iv) Medical Certificate –

a) Candidates outside Delhi have to upload the scanned copy of their Medical Examination Report as provided to them by the Civil Surgeon/Principal Medical Officer/Chief Medical Officer of the District concerned.
b) The Medical examination of the candidates residing in Delhi and those who reside outside Delhi \& wish to get their medical examination conducted in Delhi, will be conducted at designated Hospitals on a specific date and time. Their medical reports will be uploaded by this Department.
c) The medical report of the candidates who are already employed in Government Service, will also be uploaded by this Department as and when the attested copy of the same is received from their previous employer. These candidates may also opt to undergo fresh medical examination and upload the report on the portal.
d) All the candidates may submit their willingness \& Attestation Form as soon as possible to enable this Department to get the Medical Examination completed in a timely manner at designated hospitals.
5. Candidates are required to fill in and save each module completely before finally submitting the form online. Candidates will have the option to make changes in any module only before final submission of attestation form. Once final submission has been made, no change will be possible online.
6. Candidates may note that some of the fields namely Candidate’s name, Date of Birth, Category, Category selected, e-mail address, PwBDs, etc. have been pre-populated using the information provided by the candidate at the time of filling up the earlier Online Application Form for CGLE-2021. Such fields cannot be changed by the candidate. However, if a candidate notes any error/discrepancy in these fields, he may make a separate detailed representation to this office including all relevant documents in support of his/her claim at cs1-a-dopt@gov.in . This office will decide each such case on merit and its decision in such cases shall be final.
7. If any candidate presently does not have access to the mobile number furnished at the time of application, may send an email to cs1-a-dopt@gov.in citing the old mobile number and the new number, along with the reason.
8. For any queries related to Online Portal, you may contact on the e-Mail id of the Helpdesk cs1-a-dopt@gov.in constituted for the purpose. The candidates must mention the subject of the e-Mail as “CGLE-2021-Name-Rank”.


FORM OF MEDICAL CERTIFICATE

I hereby certify that I have examined $\mathrm{Sh} / \mathrm{Smt} / \mathrm{Km}$.
a candidate for employment in the Central Secretariat Service in the Government of India and cannot discover that he/she has any disease (communicable or otherwise), constitutional weakness or bodily infirmity, except $\qquad$ .

I do not consider this a disqualification for employment in Central Secretariat Service in the Government of India.
The age of Shri/Smt./Kum $\qquad$ according to his/her own statement is $\qquad$ years, and by appearance is about $\qquad$ years.
(Signature/thumb impression of the candidate)

Date $\qquad$
(To be signed in the presence of the examining Medical Officer)
img-0.jpeg

Signature of Medical Officer
Name $\qquad$
Address $\qquad$
Official Seal
(Seal should be spread over form and the photograph)

Note: The officer making this certificate should be a Civil Surgeon or a District Medical Officer of equivalent status of a Government Hospital


CANDIDATE’S STATEMENT AND DECLARATION

(The candidate must make the following statement and must sign the declaration below it before the medical officer. Attention is specially invited to the WARNING in the ‘Note’ at the bottom of page 2.)

  1. Name in full
    (in BLOCK letters)
  2. Age and place of birth
  3. Have you ever had
    (a) small-pox, intermittent fever and other fever, enlargement suppuration of glands, spitting of blood, fainting attacks, rheumatism or appendicitis? OR
    (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 relatives been afflicted by 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 fit for Govt. Service by a medical officer/ Medical Board within the last three years?
  8. Furnish the following particulars:

Father’s age, if living, \& state of health

Father’s age at the time of death and cause of death

No. of brothers living, their ages and state of health

No. of brothers who have died, their ages at death and cause of death


Mother’s age, if living, \& state of health Mother’s age at the time of death and cause of death No. of sisters living, their ages and state of health No. of sisters who have died, their ages at death and cause of death

DECLARATION

I declare that all the above answers are true and correct to the best of my knowledge and belief. I also solemnly affirm that I have not received any disability certificate/ pension on account of any disease or other condition.

Candidate’s signature
Date: $\qquad$
Signed in my presence.

Signature of Medical Officer
Name: $\qquad$
\& Designation: $\qquad$

Note: The candidate will be held responsible for the accuracy of the above statement. By wilfully suppressing any information he will incur the risk of losing the appointment and, if appointed, of forfeiting all claims to superannuation allowance or gratuity.