BEFORE THE LD.
NOTARY PUBLIC AT SILIGURI
1. I, Name Koushik Chandra Roy son of BIDHAN CHANDRA
ROY while applying for enrolment in Army Solemnly affirm &
state the following my respect :-
(a) I belong to the following caste/Religion :-
Caste Sub Caste Religion Hindu
(b) My Residential Addresses are as under :-
(i) Permanent Home Address
BIDHAN
Father Name CHANDRA ROY House No
Vill/Mohalla GURUNG BUSTY Tehsil Siliguri
District DARJEELING State WEST BENGAL
(ii) Postal Address
BIDHAN
Father Name CHANDRA ROY House No
Vill/Mohalla GURUNG BUSTY Tehsil Siliguri
District DARJEELING State WEST BENGAL
(ii) I fully understand that if enrolled, a detailed verification of my character and antecedents will be carried
out by police and civil administration from my permanent address submitted above and also places where I
have resided in the last five years.
(iii) My places of residence in the last five years are as stated under :-
Residential address in full i.e., House Number,
Lane/Street/Road, Village/Town/Mohalla, Thana, Post
Office, Tehsil and District
S/No. From To
(a)
(b)
(c)
(c) I am Unmarried.
(d) I hereby certify that I am not involved in any civil/criminal case
OR
I was involved in following cases but was acquitted :-
(i)
(ii)
OR
Following court cases / FIR are pending against me :-
(i)
(ii)
(e) Consent Certificate. I am below 18 years and my parents give their consent, for attending the Army
Recruitment Rally. (if applicable)
Signature of Father
(f) I am authorized to attend UHQ rally because I am son/ brother of No Name
Regt .
(g) I hereby certify that I, son of No Name Regt
am eligible for claiming bonus marks as none of my brothers have been enrolled in Army earlier/ I am not
eligible to claim bonus marks (Cut whichever is not applicable).
2. I am aware that there is only one recruitment rally conducted in a recruiting year (01 April to 31 March)
for every district and therefore I am entitled to attend only once every recruiting year from my home town
district based on my nativity/domicile certificate. I fully understand that if I attend another recruitment rally in
the same recruiting year, based on a different district Nativity/ Domicile certificate, my candidature will be
cancelled and if enrolled, I will be dismissed from service.
3. I am attending this recruitment rally based on the Nativity / Domicile certificate issued by
(mention the state government), details of which are as stated below :-
S/No. Cert No Date of Issue Validity Issuing authority
(a)
4. Details of nativity/domicile certificate held by me in past (if any) are as stated below :-
Present status
S/No. District Issued by Issuing date (Valid/Expired)
(a)
(b)
(c)
5. I hereby certify that till date I have attended the following Army Recruitment Rallies :-
Nativity/
Army Mon Catego Domicile
Recruitme Certificate
S/No. Recruitme th ry
nt Rally Address
nt Office and Applie
Venue used
Yea d For
r
(a)
(b)
(c)
6. I give an undertaking that all documents submitted by me are correct. All documents issued by govt org
/ offices have been signed by authorized designated and govt officials. If any document at any stage is
found fake or wrong info is furnished by me, I am aware that I will be dismissed from service and FIR will be
lodged against me .
Signature of Notary Public Signature of Candidate
