This document notifies successful candidates of the Stenographers Grade ‘C’ & ‘D’ Examination, 2020, of their allocation to the Central Secretariat Stenographers’ Service. It details the completion of pre-appointment formalities, including document submission via an online portal, medical examinations, and verification processes. Candidates are instructed to fill out willingness forms, attestation forms, and medical fitness certificates. Specific instructions are provided for candidates residing in Delhi versus those outside Delhi regarding medical examinations and police verification. The document emphasizes the importance of accurate information and the potential consequences of providing false information. It also outlines the process for submitting necessary documents and the timeline for completion.
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F No. 6/13/2022-CS.II(C)-Part(1)
Government of India
Ministry of Personnel, Public Grievances & Pensions
(Department of Personnel \& Training)
CS.II Division
$* * * * * * *$
3rd Floor, Lok Nayak Bhawan,
Khan Market, New Delhi -110003.
Dated: 11.11.2022
To
The successful candidates of
Stenographers Grade ‘C’ \& ‘D’ Examination, 2020
recommended to the grade of Stenographers Grade ‘D’ of CSSS
(As per Annexure-I)
Subject: Appointment to the grade of Stenographer Grade ‘D’ of Central Secretariat Stenographers’ Service on the basis of Stenographers Grade ‘C’ \& ‘D’ Examination, 2020 conducted by Staff Selection Commission (SSC) – Completion of pre-appointment formalities thereof.
Dear Candidates,
Congratulations on your success in the Stenographers Grade ‘C’ \& ‘D’ Examination, 2020!
I am directed to say that you have been allocated Central Secretariat Stenographers’ Service (CSSS) by Staff Selection Commission (SSC) on the basis of Stenographers Grade ‘C’ \& ‘D’ Examination, 2020.
2. The list of the candidates in annexure-I has been prepared on the basis of the dossiers received from SSC pursuant to declaration of result of Stenographers Grade ‘C’ \& ‘D’ Examination, 2020. Though utmost care has been taken while preparing the list of candidates, whose dossiers have been received in this Department, you are advised to cross check the particulars pertaining to yourself with the result declared by SSC.
3. All the successful candidates nominated for the Stenographer Grade ‘D’ of CSSS are pre-registered on the online portal (https://doptapp.nic.in/STENO/). The candidates are required to fill-up/upload and submit the following documents online:
(i) Willingness to join the post,
(ii) Attestation Form
(iii) Medical Fitness Certificate
4. The candidates, who are presently residing in Delhi or those who indicate having resided in Delhi in the point number 10 of the attestation form indicates his/her residence in Delhi should additionally fill the “Delhi Police Verification Form” given at the portal. The detailed guidelines for filling up/uploading of the aforesaid forms through the Portal are given in Annexure-II.
5. 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 with a copy of this letter, 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 (Annexure-III). The CMOs concerned are also requested to take up the Medical Examination of the candidates concerned on the strength of this letter and issue the Medical Certificate in original to the candidate. In case any other authority letter is required by the Office of
medical authority concerned, the undersigned may be contacted through mail at vinay.kumar.dopt@nic.in. The Original Medical Certificate should be sent to the undersigned within the specific period.
5.1 Candidates presently residing in Delhi, as per the information furnished in their Application form submitted to SSC, will be informed about their medical examination in due course through online portal.
5.2
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 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.
5.3
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 have to undergo their Medical Examination on allotted date and time.
6
Candidates should ensure that the requisite documents/information as sought vide paras above, are submitted/uploaded on the online portal latest by 18th November, 2022. In case of any query, candidates may contact the undersigned.
The Under Secretary (CSSS),
CS.II Division,
Department of Personnel & Training,
Room No. 10, 3rd Floor, Lok Nayak Bhawan,
Khan Market, New Delhi- 110003
Phone: 011-24652040
7
The eligibility of candidates who submit the requisite documents as above shall be determined for consideration for appointment. If found eligible, candidates will be offered appointment to the post of Stenographer Grade ‘D’ in Central Secretariat Stenographers Service subject to the verification of character and antecedents/claim for under any reserved category. The formal offer of appointment will be sent to you separately by the Cadre Controlling Authority (CCA) of the service, namely, D/o Personnel & Training. Along with the offer of appointment, the candidate will be intimated about the Mandatory Foundational Training for Stenographer Grade ‘D’ (Direct Recruit) organized by Institute or Secretariat Training and Management (ISTM) at Delhi.
8
It may be noted that the above training is mandatory and has to be completed as a part of the successful completion of probation in service. Therefore, candidates are advised to be well prepared to attend the training on the scheduled date on nomination.
9
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 fulfillment of stipulated terms and conditions.
10
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.
- 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 against furnishing of false information or submission 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.”
- The aforementioned OM dated 19.05.1993 clearly brings out that persons who secure appointment on the basis of fake/false certificates should not be retained in service and should be dismissed/removed from service.
-
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) SC/ST Candidates: – The appointment will be provisional and is subject to due verification of SC/ST certificate by the DoP&T.
(ii) OBC Candidates:- This Department has issued OM No. 36012/22/93-Estt.(SCT) dated 8 September, 1993, OM No. 36033/5/2004-Est.(Res) dated 14th 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 reservation earmarked for Other Backward Classes (OBC). The appointment is, therefore provisional to this extent and is subject to further verification of OBC certificate by the DoP&T.
(iii) PwBD Candidates: – The appointment will be provisional and subject to due verification of concerned certificate by the DoP&T.
(iv) EWS Candidates:- The appointment is provisional and is subject to the due verification of Income and asset certificate by the DoP&T.
Yours Faithfully,
(June) Kumar
Under Secretary to the Government of India
Tel: 24654020
NOTE:
- Candidates may please note that further updates/information in regard to appointment to the post of Stenographer Grade ‘D’ on the basis of Stenographers Grade ‘C’ & ‘D’ Examination, 2020 will be placed 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 Stenographers’ Service — Recruitment (Steno Grade ‘D’) (Direct Recruitment). They are, therefore, advised to regularly visit the DoP&T’s website for updates.
-
Candidates should indicate their (Stenographers Grade ‘C’ & ‘D’ Examination, 2020) All India Rank in all their correspondence with this Department, including in the subject of email.
| S. No. | Roll No | Name | Rank | Medium | DOB |
|---|---|---|---|---|---|
| 1 | 2201008331 | Pallavi Vats | 5 | English | 16-08-1999 |
| 2 | 2201021590 | Himanshu Chauhan | 6 | Hindi | 31-05-1998 |
| 3 | 2201032600 | Prerna Gera | 7 | English | 06-11-1999 |
| 4 | 4410018159 | Nikhil Rastogi | 8 | English | 23-01-2001 |
| 5 | 2201040638 | V S Shruti | 10 | English | 31-10-1997 |
| 6 | 3205601465 | Utkarsh Raj | 13 | English | 11-01-1997 |
| 7 | 2201020694 | Deepak | 16 | English | 16-03-2000 |
| 8 | 3001003960 | Sidak Preet Singh | 18 | English | 12-09-1997 |
| 9 | 2201028512 | Anshul Gupta | 22 | English | 09-08-1999 |
| 10 | 6001203406 | Hershil Jain | 23 | Hindi | 24-03-1995 |
| 11 | 2201053085 | Komal Sethi | 26 | English | 10-12-1997 |
| 12 | 2201050369 | Nandita | 30 | English | 26-12-1999 |
| 13 | 3013003141 | Arpita Srivastav | 34 | English | 01-10-1998 |
| 14 | 2409000005 | Sunder Singh Baghela | 35 | English | 15-02-1997 |
| 15 | 6005000981 | Sumit Jana | 39 | Hindi | 06-06-1997 |
| 16 | 2201053712 | Vansh Sapra | 40 | English | 08-07-2002 |
| 17 | 2201028732 | Mansi Varshney | 41 | Hindi | 09-02-1999 |
| 18 | 2201001694 | Zaved Khan | 42 | Hindi | 16-06-1996 |
| 19 | 6016000412 | Pratik Vyas | 45 | English | 12-09-1999 |
| 20 | 2201002277 | Swati Rawat | 46 | English | 28-05-1997 |
| 21 | 2201004216 | Prince Chaturvedi | 47 | English | 28-09-2000 |
| 22 | 2201038136 | Reena Raj | 48 | English | 15-10-1996 |
| 23 | 3009000749 | Prashant Shukla | 49 | Hindi | 05-09-1996 |
| 24 | 2201012737 | Muskan Sharma | 52 | English | 11-09-1999 |
| 25 | 2405018156 | Ankit Kathpal | 56 | Hindi | 18-09-1998 |
| 26 | 1601200207 | Shubham Sharma | 58 | English | 20-09-1994 |
| 27 | 6001000557 | Pranchal Yadav | 60 | English | 03-09-2001 |
| 28 | 2201050608 | Rupali Bisht | 63 | English | 13-10-2000 |
| 29 | 3205601635 | Nisha Kumari | 65 | Hindi | 17-03-1997 |
| 30 | 2405006871 | Naval Meena | 67 | Hindi | 21-12-1998 |
| 31 | 3206611461 | Manish Kumar Sinha | 68 | English | 28-08-1999 |
| 32 | 3013608306 | Anand Kumar | 69 | English | 22-02-1996 |
| 33 | 2201051811 | Shubham Gupta | 70 | English | 01-03-1996 |
| 34 | 1403000664 | Himanshi | 71 | English | 14-07-1999 |
| 35 | 2201025613 | Amit Rana | 74 | English | 05-09-1999 |
| 36 | 3011002919 | Amit Kumar | 76 | English | 13-08-1999 |
| 37 | 4205002363 | Sandhya Rani | 77 | English | 02-08-1997 |
| 38 | 2201028383 | Udit Agrawal | 79 | Hindi | 31-08-1999 |
| 39 | 3003604211 | Vivek Pandey | 80 | Hindi | 21-08-1997 |
| 40 | 3009601507 | Bharat Gupta | 82 | Hindi | 08-07-1998 |
| 41 | 4205015523 | Shweta Kumari | 83 | English | 25-09-1998 |
| 42 | 2201014903 | Sourav | 84 | English | 05-05-1996 |
| 43 | 2201055382 | Piyush Kumar | 85 | English | 04-09-2001 |
| 44 | 3009605959 | Prashant Pandey | 86 | Hindi | 22-08-1995 |
| 45 | 4205002057 | Rajeev Kumar Singh | 88 | English | 04-09-1999 |
| 46 | 2201043455 | Jatin Kumar Walia | 89 | English | 03-06-1996 |
| 47 | 2405019552 | Arpit Kumar Rukhaya | 90 | Hindi | 03-09-1996 |
|---|---|---|---|---|---|
| 48 | 3206601663 | Sanjeev Kumar | 91 | English | 21-02-1999 |
| 49 | 2201052989 | Dipesh | 92 | English | 12-10-1994 |
| 50 | 2201047212 | Yogesh Chowdhary | 94 | English | 06-11-1994 |
| 51 | 6005201549 | Akash Ojha | 95 | English | 06-08-1999 |
| 52 | 2201053330 | Ashish Kumar | 96 | English | 06-12-1996 |
| 53 | 2201021677 | Apaala Ghai | 98 | English | 03-09-1999 |
| 54 | 2201048461 | Jyoti Shahi | 99 | English | 11-04-2000 |
| 55 | 2201010944 | Sandeep Kumar | 111 | English | 14-08-1998 |
| 56 | 3001600850 | Kamal Patlani | 120 | English | 03-04-1998 |
| 57 | 2002007011 | Vishal | 130 | English | 18-01-2002 |
| 58 | 2201043766 | Mayank Sharma | 131 | Hindi | 21-04-1996 |
| 59 | 3206004637 | Sanjivan Kumar | 133 | Hindi | 02-08-2000 |
| 60 | 2003005329 | Mohit Kumar | 137 | Hindi | 15-05-2000 |
| 61 | 2201004807 | Nishant Rajat | 147 | English | 27-11-1993 |
| 62 | 2201032809 | Sachin Yadav | 149 | English | 10-09-1996 |
| 63 | 2201018994 | Someshwar Gautam | 161 | English | 04-01-1998 |
| 64 | 2201031462 | Pratiksha Yadav | 162 | English | 10-05-1995 |
| 65 | 2201022815 | Neha Yadav | 168 | English | 26-06-1999 |
| 66 | 2201004075 | Sumit | 183 | English | 29-07-1999 |
| 67 | 3206011102 | Shubham Kumar | 184 | Hindi | 06-11-1997 |
| 68 | 2405018384 | Sunil | 187 | Hindi | 06-09-1998 |
| 69 | 2201053277 | Anu | 190 | English | 18-06-1996 |
| 70 | 2405002952 | Devansh Choudhary | 191 | Hindi | 11-05-2001 |
| 71 | 2201031647 | Rakesh Kumar Tiwari | 198 | English | 25-11-1995 |
| 72 | 2002005517 | Mohd Zubair Alam | 202 | Hindi | 15-08-1999 |
| 73 | 2002005731 | Keerti Soni Anand | 206 | English | 25-10-2000 |
| 74 | 2201016234 | Omkar | 207 | English | 02-08-2000 |
| 75 | 3206003068 | Ankit Kumar | 228 | Hindi | 13-06-1996 |
| 76 | 3009601914 | Varun | 232 | English | 02-02-2020 |
| 77 | 3015600486 | Sameer Ahmad | 238 | Hindi | 07-07-2000 |
| 78 | 3009002353 | Anuj Shivhare | 247 | Hindi | 30-04-1999 |
| 79 | 3001603089 | Gudiya Yadav | 250 | English | 10-12-1994 |
| 80 | 2002005473 | Mohd Aizaz Saifi | 253 | Hindi | 17-03-2002 |
| 81 | 2201047550 | Aman Kumar | 255 | Hindi | 24-09-1991 |
| 82 | 2201042564 | Lata | 260 | English | 07-10-1998 |
| 83 | 2201051502 | Chhavi Katiyar | 261 | English | 20-02-1999 |
| 84 | 3206601397 | Anshal Kumar | 265 | English | 09-01-1998 |
| 85 | 2201044882 | Sahil Yadav | 266 | English | 13-06-2001 |
| 86 | 2201008459 | Dipak Sharma | 267 | English | 01-01-2001 |
| 87 | 3010005744 | Harshit Vishwakarma | 275 | Hindi | 19-09-1998 |
| 88 | 3015000592 | Rohit Kumar | 285 | Hindi | 25-12-2000 |
| 89 | 2201037710 | Megha Panwar | 289 | English | 13-09-1996 |
| 90 | 6005203289 | Vineet Rathor | 295 | Hindi | 23-06-2000 |
| 91 | 3010002495 | Narendra Gupta | 298 | Hindi | 01-08-1998 |
| 92 | 2409001799 | Aastha Acharaj | 303 | English | 08-06-2000 |
| 93 | 2201051144 | Amit Kumar Kain | 306 | English | 07-01-1992 |
| 94 | 3202600523 | Raunak Raj | 311 | English | 17-03-2002 |
| 95 | 3003001684 | Anshika Kesarwani | 312 | English | 19-08-1999 |
|---|---|---|---|---|---|
| 96 | 2201014781 | Sachin Yadav | 318 | Hindi | 01-12-1997 |
| 97 | 2201010606 | Neeraj Sharma | 335 | English | 26-09-1994 |
| 98 | 3206604739 | Anish Kumar | 342 | Hindi | 08-12-1994 |
| 99 | 2201052790 | Sahil | 355 | English | 15-08-1997 |
| 100 | 2201035093 | Abhishek Prakash | 356 | English | 26-12-1989 |
| 101 | 2201035548 | Yash Moreya | 359 | English | 23-01-2001 |
| 102 | 2201020618 | Vinita | 377 | English | 26-11-1996 |
| 103 | 2201004157 | Geetanjali | 398 | English | 31-07-1999 |
| 104 | 2201045517 | Yogesh Kumar | 404 | English | 17-03-2001 |
| 105 | 2003003238 | Ritik Chauhan | 417 | Hindi | 18-07-2000 |
| 106 | 2201016582 | Shalini Rani | 418 | English | 01-04-1995 |
| 107 | 2201007364 | Yashna | 441 | English | 24-07-1999 |
| 108 | 2201013328 | Aryan Kumar | 457 | English | 06-01-2002 |
| 109 | 2201008451 | Reeya Kaur | 458 | English | 21-08-1994 |
| 110 | 3206013011 | Shubham Kumar Nirala | 464 | English | 28-03-1994 |
| 111 | 2201047853 | Aditi Tomar | 465 | English | 15-04-2000 |
| 112 | 2201010492 | Rohit Goyal | 467 | English | 05-10-1997 |
| 113 | 2201018966 | Zaid Khan | 468 | Hindi | 08-09-2001 |
| 114 | 3009604639 | Nikhil Agarwal | 485 | Hindi | 25-11-1999 |
| 115 | 2201043995 | Rahul Meena | 515 | English | 02-07-1998 |
| 116 | 2201015159 | Taniya | 615 | English | 09-08-2000 |
| 117 | 3008920004 | Rishabh Rathore | 617 | Hindi | 10-08-1996 |
| 118 | 2402000958 | Neelam | 619 | Hindi | 22-05-2000 |
| 119 | 2405020844 | Goverdhan Lal Meena | 620 | Hindi | 04-09-1996 |
| 120 | 4410020494 | Leena Tudu | 622 | English | 26-04-1994 |
| 121 | 2201039769 | Kimlalnei Singsit | 625 | English | 18-09-1999 |
| 122 | 2201019860 | Himanshi Turkiya | 626 | English | 13-11-1999 |
| 123 | 3003930007 | Abhinav Dwivedi | 628 | English | 03-04-2001 |
| 124 | 2201015210 | Sachin Sharma | 632 | Hindi | 26-01-1995 |
| 125 | 2405014625 | Ravi Meena | 633 | English | 20-08-2001 |
| 126 | 2405019920 | Manoj Meena | 636 | Hindi | 04-05-2001 |
| 127 | 2402003335 | Balram Meena | 639 | Hindi | 01-01-1998 |
| 128 | 2201049041 | Rakesh Malik | 665 | English | 07-11-1981 |
| 129 | 2201015128 | Vishesh Kumar | 679 | Hindi | 20-08-2001 |
| 130 | 2002002548 | Vinod Chhetri | 688 | Hindi | 10-10-1984 |
| 131 | 2402000679 | Mukesh Singh Rajput | 689 | Hindi | 24-04-1983 |
| 132 | 2002000535 | Sanjeev Raturi | 690 | Hindi | 25-11-1987 |
Guidelines for completion of pre-appointment formalities to the post of Stenographer Gr. ‘D’ in CSSS selected on the basis of Stenographer Gr. ‘C’ and ‘D’ Examination-2020 on Online Portal (https://doptapp.nic.in/STENO/).
Note: Candidates are advised to read the following instructions before completion of 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/Voter ID/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)
- It may be noted that candidates who have been selected for the post of Stenographer Gr. ‘D’ in CSSS on the basis of Stenographer Gr. ‘C’ and ‘D’ Examination – 2020 are pre-registered with basic details (like-Name, Roll No. Rank, Category, DoB, Mobile Number, e-mail id) on the Online Portal.
- 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.
- 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 passwords set by them and update their profile.
- 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 copies of the same are 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, etc. have been pre-populated using the information provided by SSC in the successful candidate’s dossier. 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 vinay.kumar.dopt@nic.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 vinay.kumar.dopt@nic.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 vinay.kumar.dopt@nic.in constituted for the purpose. The candidates must mention the subject of the e-Mail as “Stenographer Gr. ‘C’ and ‘D’ Examination -2020-Name-Rank”.
FORM OF MEDICAL CERTIFICATE
I hereby certify that I have examined $\mathrm{Sh} / \mathrm{Smt} / \mathrm{Km}$. $\qquad$ 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)

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.)
- Name in full
(in BLOCK letters) - Age and place of birth
- 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? - When were you last vaccinated?
- Have you or any of your relatives been afflicted by consumption, scrofula, gout, asthma, fits, epilepsy or insanity?
- Have you suffered from any form of nervousness due to overwork or any other cause?
- Have you been examined and declared fit for Govt. Service by a medical officer/ Medical Board within the last three years?
- Furnish the following particulars:
Father’s age, if Father’s age at the living, & state of 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: $\qquad$
$\qquad$
$\qquad$
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.