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:
b. Permanent
a. Present

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 15 th
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
 TELANGANA PUBLIC SERVICE COMMISSION # HYDERABAD
PHARMACIST GRADE.II IN DIRECTOR OF PUBLIC HEALTH & FAMILY WELFARE,
DIRECTOR OF MEDICAL EDUCATION AND TELANGANA VAIDYA VIDHANA PARISHAD
(HEALTH, MEDICAL& FAMILY WELFARE DEPARTMENT) (GENERAL RECRUITMENT)
(GENERAL RECRUITMENT) NOTIFICATION NO: 04/2018
BASIC INFORMATION DATA
(CHECK LIST)
(To be filled by the candidate)

TSPSC ID :

Ref ID : PHOTO OF THE

CANDIDATE
HALL TICKET NO :

DATE OF VERIFICATION:

Signature
Name of the Candidate
01
( 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)
Years Months days
(Age as on 01/07/2017)
06

A) Intermediate Date of Pass

B) D. Pharmacy Date of Pass

07 Qualification
(as on 25/01/2018)

Official use:

Registration Number Date of Registration

Details of Registration
08 with Pharmacy Council
Official use:

OC SC ST BC
A B C D E
Community (integrated
Community Certificate
Issued by M.R.O for
09
SC/ST/BC from Official use:
Telangana State Govt)
 Whether non-creamy
BC Candidates should YES NO
layer certificate
Submit Non Creamy produced
Layer certificate as per
G.O.Ms.No:8 of 2014
10
Official use:
&
MemoNo.3009/BCW/
OP/2011, Dt: 18-12-2015.

If age relaxation is
Whether relevant Certificate
claimed, specify
Years Produced
.
1) Retrenched Census
11 (No. of years claimed for YES NO
Employee
relaxation)
2) Telangana State
Govt. Employee Official use:
3) N.C.C
4) Ex-Service Men
5) SC/ST and BC

Class Year District State

IV
Indicate the evidence
(Original Study
V
Certificate to be
produced) OR
12 VI
Residence certificate for
7 yrs. Prior to SSC if
private Study. VII

VIII

IX

District to which Other Than

13
Belongs. Telangana

Present Employment
details
14 (Government Employees
should submit NOC) Official use:

1.
Other Certificates
15 (If any)
2.
 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, my educational qualification, community certificate, date 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 involved in any unfair means
/ malpractice.
v) I further declare that the information furnished by me is correct and my candidature shall be
16 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 Admitted.

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

TO BE USED FOR REJECTION

The Candidate Rejected for the following reason.

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

MEMBER CHAIRMAN
 FORM FOR COMMUNITY, NATIVITY AND DATE OF BIRTH CERTIFICATE

Serial No.

S.C. Seal of the District Code:

S.T Issuing Mandal Code :
B.C Office Village Code :
Certificate No:

COMMUNITY, NATIVITY AND DATE OF BIRTH CERTIFICATE

(1) This is to certify that Sri/Smt./Kum.

Son/Daughter of Sri of Village/Town
Mandal District of
the State of Telangana belongs to Community which is recognised as (*)
S.C./S.T./B.C. sub-group

The Constitution (Scheduled Castes) Order, 1950

The Constitution (Schedule Tribes) Order, 1950

G.O.Ms.No:1793, Education, dated:25.9.1970 as amended from time to time (BCs.) /

S.Cs., S.Ts. list (modification) Order, 1956 S.Cs. and S.Ts. (Amendment) Act, 1976.

(2) It is certified that Sri/Smt./Kum. is

a native of Village/Town Mandal District of Telangana.

(3) It is certified that the place of birth of Sri/Smt./Kum.

is Village/Town Mandal
District of Telangana.

(4) It is certified that the date of birth of Sri/Smt./Kum.

is Day Month Year
(in words) as per the declaration given by his/her
father/mother/guardian and as entered in the school records where he/she studied.

Signature:
Date:
Name in Capital Letters:
Designation:
(seal)

Explanatory Note:- While mentioning the community, the Competent Authority must
mention the sub-caste (in case of Scheduled Castes) and sub-tribe or sub-group (in case of
Scheduled Tribes) as listed out in the S.Cs. and S.Ts. (Amendment) Act, 1976.
 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)
 GOVERNMENT OF TELANGANA
REVENUE DEPARTMENT
Application No

RC
Date : / / .
CERTIFICATE OF RESIDENCE
(To be produced by such candidates who have not studied in any educational institution during the
whole or any part of the relevant 4 or 7 years period but claimed to be local candidates by virtue of
residence for post codes for which there is reservation for local candidates)

It is hereby certified.
(a) that Sri/Srimathi/Kumari S/o / D/o / W/o
th
appeared for the first time for the 7 Class examination
in (month) (Year).
(b) that he/she has not studied in any educational institution during the of the
consecutive academic years ending with the academic year in which he/she
first appeared for the aforesaid examination.
(c) that in the years immediately preceding the commencement of the
aforesaid examination he/she resided in the following place/places namely.
Sl. No. Village Mandal District Period

Certified By
Station :
State : Telangana
Name :
Designation :
Mandal :
District :