TELANGANA PUBLIC SERVICE COMMISSION # HYDERABAD

GROUP-IV SERVICES

(GENERAL RECRUITMENT) NOTIFICATION NO: 19/2022, DATED 01/12/2022

To the Post of Junior Accountant, Junior Auditor, Junior Assistant, Matron Gr-II, Matron/Matron
cum Store Keeper, Supervisor, Ward Officer

BASIC INFORMATION DATA: (CHECK LIST)

(To be filled by the candidate)

PHOTO OF THE
TGPSC ID : CANDIDATE

Ref ID :

HALL TICKET NO :

SIGNATURE

VENUES : 1) O/o TGPSC, Prathibha Bhavan, Nampally, Hyderabad and

2) Potti Sreeramulu Telugu University, Lalitha Kala Kshetram, Public
Gardens, Hyderabad. (New building behind Temple.)
DATE OF VERIFICATION:
AND SESSION

01 Name of the Candidate

(As per SSC)

02 Father’s Name

03 Mother’s Name

04 Gender Male Female

Date of Birth D D M M Y Y Y Y
05
(As per SSC)

(Age as on Years Months Days

06 01/07/2022)

If age relaxation is
claimed, specify (No. of years claimed for Whether relevant Certificate
1. Retrenched relaxation) Produced
Census Employee
2.Telangana State YES NO
Govt. Employee
07 3. N.C.C Instructor
4. SC/ST and BC &
EWS.
5. Ex-Service Men
 Date of Name of
Qualification Qualificationof Acquiring Name of the State
Prescribed as the Qualificatio the inwhich
Qualification per Notification Candidate. n by the University the
(As on 01/12/2022) candidate . University
is
located.
08

009 Pe

OC SC ST BC
09 Percentage of Marks in
Degree

BC
Community OC SC ST EWS
(integrated Community A B C D E
Certificate Issued by
Tahsildar for
10
SC/ST/BC& EWS from
Telangana State Govt) Official use:

BC Candidates should
Submit Non-Creamy
Layer certificate Whether non-creamy layer
YES NO
11 (Annexure-II FormVII-B) certificate produced
as per G.O.Ms.No.8,
B.C. Welfare (OP) Dept,
Dt: 13-11-2014,
MemoNo.3009/BCW/
OP/2011, Dt:
18/12/2015 and
G.O.Ms. No:20 of
2017

MeeSeva/Online MeeSeva/Online
Candidates claiming Date of issue of EWS Certificate for the
EWS Reservation as per EWS Certificate for the year 2021- Year 2021-2022
G.O.Ms.No.243 & 244 2022 furnished
12
GA (SER.D) Dept., Yes No
Dt. 24/08/2022 for the
year 2021-2022

Do you belongs to VH % OH % HH % MH %
13 PWD category, if yes
mention Disability and
percentage

Is the Candidate Details of Sports reservations

14 claiming any Sports
reservation, if yes
give details
 Date of
issue of
Indicate the evidence Class Year District State Study
/Residential
15 (Original Study Certificate
Certificate to be
produced) OR Class – I
Residence certificatefor Class - II
7 yrs. Prior to 7th Class,
Class - III
if private Study.
Class - IV
Class - V
Class - VI
Class - VII
District to which you
16
belong
Do you belongs to Ex- Yes No
17 Servicemen, If yes, give
details and enclose
certificate.
Present Employment
details
(Government
18 Employees should
submit NOC)
Yes No
Whether exercised Web
19
Options,

Have you applied for Post Yes No Whether self-declaration submitted

Code 70
20
If yes, submit self- Yes No
declaration
Have you applied for Post Yes No Whether relevant certificate produced
Code 94 (Only Women)
If yes, produce a medical Yes No
21
certificate from not below
the rank of Govt. Civil Asst.
Surgeon
Have you applied for Post Yes No Whether relevant certificate produced
Code 95 (Men & Women)
If yes, produce a medical Yes No
22
certificate from not below
the rank of Govt. Civil Asst.
Surgeon
Have you applied for Post Date of passing : Whether relevant certificate produced
Code 03 University :
23 University Location :
If yes, give academic
details (B.Com) Yes No
Degree : Whether relevant certificate produced
Date of passing :
Have you applied for Post University :
Code 15 University Location :
If yes, give degree
24 aggregate percentage Percentage in Percentage in Yes No
Degree for Others Degree for SC / ST

Have you applied for Post Degree : Whether relevant certificate produced
Code 61 B (F &A), Date of passing :
25 If yes, give academic University :
details (B.Com Computers) University Location : Yes No
 Declaration
I hereby declare that

i) All the columns filled in by me containing my biodata and other particulars, are true to the best of my
knowledge.
ii) The certificates such as, educational qualification, community certificate, dates of birth (SSC),
study/residence in support of my claim for local candidature are genuine.
iii) I did not resort to any irregular or improper means in connection with my candidature for selection.
iv) I am liable for permanent debarment from appearing for the recruitment to be conducted by TSPSC
and other PSCs and also criminal prosecution, if I am found to be involved in any unfair means /
malpractice.
17
v) I further declare that the information furnished by me is correct and my candidature shall be cancelled
at any stage if it is found incorrect.
Address.

…………………………………………………...

…………………………………………………..

…………………………………………………..

Mobile No………………………………………

Place:
Date: Signature of the candidate.

TO BE USED FOR ADMISSION (OFFICIAL USE)

The Candidate is Admitted for further process of selection, since he/she possessall qualifications
as per Notification.

A.S. O SECTION OFFICER ASST.SECRETARY DEPUTY SECRETARY

TO BE USED FOR REJECTION

The Candidate is Rejected for further process of selection because of thefollowing reason.
i). ii).

iii). Iv).

A.S. O / SECTION OFFICER ASST.SECRETARY DEPUTY SECRETARY

 1

ATTESTATION FORM
Latest colour
(THE CANDIDATES SHOULD PROPERLY FILL THE ATTESTATION passport size
FORM WITH HIS/HER OWN HAND WRITING) Photograph of
the candidate

Name of the Name of the Head

Department of the Dept.

1.(a) Name in full (capital letters only with aliases, if any. Please indicate if you
have added / dropped at any stage any part of your name/surname.

SURNAME

NAME

(b) Designation of the candidate with category (Appointment by Direct

Recruitment/Ex- Servicemen quote/compassionate ground)
Enclose supporting certified copies of the documents

(i) Designation

(ii) Place of Working

(iii) Direct recruitment Ex-Serviceman Compassionate

2. Details of addresses:
a. Present b. Permanent

House/Apartment/Flat No.

Name of Apartment

Lane Name

Street & Road

Village

Mandal / Taluk

Town / City

District

State

Pin Code
 2

Landline office Landline Residence

Mobile
(with STD Code) (with STD Code)
Contact Phone Numbers

(c) If originally a resident

Of Pakistan, the address
in that Dominion and the
date of migration to Indian
Union

3. Particulars of places where you have resided during the preceding five years
from the date of filling up if Attestation From.

Residential Address in full

( i.e., House / Apartment /
Flat Number)
From To Police station and
( Apartment/Complex/Lane/
(Month / Year) (Month / Year) District
Street/Colony and Road,
Village,Mandal and District/City)

1
2
3
4
5

4. Father’s details:
(a) Name in full with aliases, if any

(b) Profession

(c) If in service, give designation and

official address

(d) Present postal address (if dead, House No.

give last address
Lane Name
Street & Road
Village/Mandal
Dist
State
Pin Code

(e) Permanent House Address House No.

Lane Name
Street & Road
Village/Mandal
Dist
State
Pin Code
 3

5. (i) Nationality of :
(a) Father

(b) Mother

(c) Wife / Husband

(ii) Place of Birth of Wife / Husband

6. (a) Date of birth of the applicant

(b) Present Age

(c) Age at SSC / Matriculation

7. (a) Place of birth, District and State

(b) District and State to which you belong

8. (a) Religion

(b)Are you member of Scheduled Caste / Scheduled Tribe / Backward Class?

Scheduled Caste Scheduled Tribe Backward Class

Please specify the Class / Tribe Grade A,B,C,D & E

9. Educational Qualifications showing places of education with years in schools and colleges since 15th
year of age (Please enclose certified copies of Study Certificates and indicate whether study is
regular or distance / correspondence).

Name of the
School / College Date of Date of Examination passed
with full entering leaving with Reg.No.etc. Police
Course address (mention (mention (Name of the group Station and
(Village / month month i.e.,Inter/Degree/ District
Mandal & year) & year) Diploma/ PG,etd
/ District / City
1. SSC/
Matriculation

2.Intermediate
Diploma
3. Graduation/
Professional
Course
4. Post
Graduation

5. Any other
qualification
 4

10. If you have at any time been employed, give details, (Please enclose certified copies of the
documents).
Have you been at any
Designation of Post Period Full Address of the time dismissed /
held or description of Office, Firm or removed from service /
work From To Institution resigned to the post? If
so, please give details.

11. Have you ever been arrested by the police, convicted by a Court of law or detained under any
state /central preventive detention laws for any offence? Whether such conviction sustained in
the Court of Appeal or set aside by the Appellate Court if appealed against.
(Note: If detailed, convicted, debarred etc. subsequent to the completion and submission of this
form, the details should be communicated immediately to the concerned Department or the
authority to whom the Attestation Form has been sent earlier, as the case may be, failing which it
will be deemed to be suppression of factual information). If the answer is ‘Yes’, the full
particulars of the conviction, sentences and detention should be given.

12. Name and complete address of two responsible persons of your locality to whom you are known or
two referees to whom you are known. (Persons shall not be blood relatives).

Referee-1 Referee-2
Name

H.No./Plot No.

Name of Apts./
Complex

Street & Road

Village

Mandal/Taluk

Town/City

District

State

Pin Code

13. Have you ever been member/worker of any Political Party or Communal
organization/Youth/Student/Service/Labour? If so furnish details
 5

DECLARATION SHOULD BE SIGNED BY THE CANDIDATE

1. I here declare that the statements made in this form are true to the best of my knowledge and
belief.

2. I am married/unmarried and have only one wife living (delete which is not applicable).

3. I am fully aware that furnishing of false information or suppression of any factual information
in the Attestation Form would be a disqualification and is likely to render me unfit for
employment under the Government.

4. I am also fully aware that if it comes to notice at any time during my service that false
information has been furnished or that there has been suppression of factual information in the
Attestation Form, my services would be liable to be terminated solely on this ground.

Date: Signature of Candidate

Place:

CERTIFICATE TO BE SIGNED BY A GAZETTED OFFICER OR MEMBER OF

LEGISLATURE OR OTHER AUTHORITY AS PRESCRIBED BY THE
APPOINTING AUTHORITY

Certified that I have known Sri / Smt / Kum.

Son / Daughter / Wife of

For the last years months and to the best of my knowledge and belief,

the particulars furnished by him / her are correct.

Date: (Signature)
Name & Designation with Seal
Place:

Photograph of the
candidate attested
by Gazetted Officer
/ MLA / other with
seal Competent
Authority
 DECLARATION BY THE UN-EMPLOYED
Who claim fee exemption

1. Name of the Candidate :

2. Father’s Name :

3. Date of Birth & Age :

4. Centre for Written Examination

5. Full Postal Address :

I hereby declare that I am not working in any Government Department/ Quasi

Government/Public Sector/Private Sector.

I further declare that the information furnished by me is true and correct and my
candidature shall be cancelled at any stage if it is found incorrect.

PLACE FULL SIGNATURE OF THE CANDIDATE.

(Declaration not signed by the candidate
DATE will be rejected)
 GROUP-IV SERVICES (Notifn.No. 19/2022)
DECLARATION AS HINDU
who applied for the post code No.70 in Endowment Department

1. TS_ID :

2. Hall Ticket Number :

3. Name of the Candidate :

4. Father’s Name :

5. Date of Birth & Age :

6. Religion :

7. Full Postal Address :

I hereby declare that I belong to Hindu Community. The information

furnished by me is true and correct to the best of my knowledge and belief and
my candidature shall be cancelled at any stage if it is found incorrect.

PLACE FULL SIGNATURE OF THE CANDIDATE.

(Declaration not signed by the candidate will be rejected)
DATE