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Forms Certificate

This document contains a character certificate, medical certificate, caste certificate, family details form, disability certificate, and declaration form commonly used for government employment in India. The character certificate certifies the good character of an individual based on the knowledge and belief of the signatory. The medical certificate examines a candidate for employment and certifies their medical fitness. The caste certificate verifies the caste or tribe of an individual as recognized under India's reservation system. The family details form collects information about an applicant's family members. The disability certificate assesses and certifies the nature and percentage of an individual's disability. The declaration form requires the applicant to declare their marital status.

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Myheart MD
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97 views6 pages

Forms Certificate

This document contains a character certificate, medical certificate, caste certificate, family details form, disability certificate, and declaration form commonly used for government employment in India. The character certificate certifies the good character of an individual based on the knowledge and belief of the signatory. The medical certificate examines a candidate for employment and certifies their medical fitness. The caste certificate verifies the caste or tribe of an individual as recognized under India's reservation system. The family details form collects information about an applicant's family members. The disability certificate assesses and certifies the nature and percentage of an individual's disability. The declaration form requires the applicant to declare their marital status.

Uploaded by

Myheart MD
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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चरित्र प्रमाणपत्र CHARACTER CERTIFICATE

Certified that I have known Shri/Smt/Kum ……………………………………........................…

son/daughter of Shri/Smt.………………………………………...for the last ...... years.......months


and that to the best of my knowledge and belief he/she bears a reputable character and has
no antecedents which render him/her unsuitable for Government employment.

2. Shri/ Smt/Kum …………………………………………………….. is not related to me.

Date: Signature

Place: Name

Office Seal Designation of the post held at present

चरित्र प्रमाणपत्र CHARACTER CERTIFICATE

Certified that I have known Shri/Smt/Kum ……………………………………........................…

son/daughter of Shri/Smt.………………………………………...for the last ...... years.......months


and that to the best of my knowledge and belief he/she bears a reputable character and has
no antecedents which render him/her unsuitable for Government employment.

2. Shri/ Smt/Kum …………………………………………………….. is not related to me.

Date: Signature

Place: Name

Office Seal Designation of the post held at present

This should be done after the candidate has been finally selected for appointment
Certificate to be signed by any one of the following:

i) Gazetted officers of Central or State Government


ii) Members of Parliament or State Legislature belonging to the constituency where
the candidate or his parent/guardian is ordinarily resident;
iii) Principal/Head Master of the recognized School/College/Institution where the
candidate studied last:
iv) Post Master.
चचकित्सा प्रमाणपत्र MEDICAL CERTIFICATE

I do hereby certify that I have examined Shri./ Smt./ Kum.


………………………………a candidate for employment in the Customs Department and
cannot discover that he/she has any disease (Communicable or otherwise),
constitutional weakness or bodily infirmity except ________________. I do not
consider this as a disqualification for employment in the office of the Commissioner
of Customs, Cochin-09. His / her age is according to his/her own statement
..........................years by appearance about ...........................years.

Personal marks of identification:

1.

2.

Signature
Name and Designation of the Medical Officer
Station: with Reg. No. and address
Date:

Office Seal Signature of the Candidate


जाति प्रमाणपत्र CASTE CERTIFICATE

This is to certify that Shri/Smt/Kum ………………………………… son/daughter of


Shri. …………………………………. of Village/Town ……………………….. in District/Division
………………………….. of the State/Union Territory ………………………... belongs to the
……………………………… Caste/Tribe which is recognized as a Scheduled Caste/Scheduled
Tribe / Other Backward Classes under the Scheduled Castes and Scheduled Tribes (lists)
modification, 1956. The Constitution (Jammu and Kashmir) Scheduled Caste Order, 1956,
the Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1959, the
Constitution (Dadar & Nagar Haveli) Scheduled Castes Order, 1962, the Constitution (Dadar
& Nagar Haveli) Scheduled Tribes Order, 1962.

2. Shri/Smt/Kum …………………………………………. and/or/his/her family ordinarily


reside(s) in Village*/Town ……………………………………………………………… of
…………………………………….District/Division* …………………………………….. of the
………………………………. State*/Union Territory of ……………………………………….

* Please delete the words which are not applicable

Note: The term “Ordinarily resides” used here will have same meaning as in Section 20 of the
representation of the People Act ,1950.

****************
F O R M –3

DETAILS OF FAMILY

Name of the Government Servant : ……………………………………………….

Designation : ……………………………………………….

Date of Birth : ……………………………………………….

Date of Appointment : ……………………………………………….

Details of the members of my family as on ………………………………………………..

Sl. No. Name of the members Date of Relationship Initials Remarks


Members of Birth with the of the
Family* official head of
Office

1.

2.

3.

4.

5.

6.

7.

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

I hereby undertake to keep the above particulars upto date by notifying to the Head of
Office any addition or alteration.

Signature of the Govt. Servant.

Place:

Date:

* Family for this purpose means family as defined in clause (b) of sub-rule (14) of Rule 54 of
the CCS (Penson) Rules, 1972.

Note: Wife and husband shall include respectively judicially separated wife and husband.
NAME & ADDRESS OF THE INSTITUTE/HOSPITAL
Certificate No. ——————- Date——————-
दिव्ाांगिा प्रमाणपत्र DISABILITY CERTIFICATE
This is certified that Shri/Smt/Kum ________________ son/wife/daughter of Shri __________
___________ age _____________sex ____________identification mark(s) _______________________
is suffering from permanent disability of following category :-

A. Locomotor or cerebral palsy : Affix here recent


(i) BL-Both legs affected but not arms. attested
Photograph
(ii) BA-Both arms affected (a) Impaired reach Showing the
(b) Weakness of grip disability duly
attested by the
(iii) BLA-Both legs and both arms affected chairperson of the
Medical Board
(iv) OL-One leg affected (right or left) (a) Impaired reach
(b) Weakness of grip
(c) Ataxic

(v) OA-One arm affected (a) Impaired reach


(b) Weakness of grip
(c) Ataxic
(vi) BH-Stiff back and hips (Cannot sit or stoop)

(vii) MW-Muscular weakness and limited physical endurance.

B. Blindness or Low Vision : (i) B-Blind


(ii) Partially Blind

C. Hearing Impairment : (i) D-Deaf


(ii) PD- Partially Deaf

( DELETE THE CATEGORY WHICHEVER IS NOT APPLICABLE )

2. This condition is progressive/non-progressive/likely to improve/not likely to improve. Re-


assessment of this case is not recommended/is recommended after a period of _____ years
____ months.*
3. Percentage of disability in his/her case is ..................... percent.
4. Sh./Smt./Kum ............................. meets the following physical requirements for
discharge of his /her duties :-

(i) F-can perform work by manipulating with fingers. Yes/No


(ii) PP-can perform work by pulling and pushing. Yes/No
(iii) L-can perform work by lifting. Yes/No
(iv) KC-can perform work by kneeling and crouching. Yes/No
(v) B-can perform work by bending. Yes/No
(vi) S-can perform work by sitting. Yes/No
(vii) ST-can perform work by standing. Yes/No
(viii) W-can perform work by walking. Yes/No
(ix) SE-can perform work by seeing. Yes/No
(x) H-can perform work by hearing/speaking. Yes/No
(xi) RW-can perform work by reading and writing. Yes/No

(Dr.______________________) (Dr.__________________________) (Dr.___________________________)


Member, Medical Board Member, Medical Board Chairperson, Medical Board

Countersigned by the Medical Superintendent/

CMO/Head of Hospital (with seal)

*Strike out which is not applicable.


घोषणा D E C L A R A T I O N

I Shri/Smt./Kumari ……………………………………………………declare as under:


* (i) that I am unmarried/a widower/a widow
*(ii) that I am married and have only one wife living
*(iii) that I am married and my husband has no other living wife, to the best of my knowledge.
*(iv) that I am married and have more than one wife living. Application for grant of exemption
is enclosed
*(v) that I am married to a person who has already one wife or more living. Application for
grant of exemption is enclosed.

@ I solemnly affirm that the above declaration is true and I understand that in the event of
the declaration being found to be incorrect after my appointment, I shall be liable to be
dismissed from service.

Signature:…………………….
Note: * Please delete clauses not applicable
@ Application in the case of clause (i), (ii) and (iii)only

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

APPLICATION FOR GRANT OF EXEMPTION

To
The Additional Commissioner of Customs (P&V),
Custom House,
Cochin-9.

Madam,

I request that in view of the reasons stated below, I may be granted exemption from
the operations of restriction on the recruitment to service of person having more than one
wife living/women who is married to a person already having one wife or more living.

/ Reasons /

Yours faithfully,

Signature: ……………………………………

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