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Self Declaration Form

The document is a self-declaration by Bibekananda Prusty, confirming the accuracy of the information provided in the application for a certificate as per Odisha Miscellaneous Certificate Rules, 1984. It includes personal details such as age, caste, and purpose for employment. The applicant acknowledges responsibility for the truthfulness of the declaration and potential legal consequences for false information.

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Sridhar Panigrahi
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331 views1 page

Self Declaration Form

The document is a self-declaration by Bibekananda Prusty, confirming the accuracy of the information provided in the application for a certificate as per Odisha Miscellaneous Certificate Rules, 1984. It includes personal details such as age, caste, and purpose for employment. The applicant acknowledges responsibility for the truthfulness of the declaration and potential legal consequences for false information.

Uploaded by

Sridhar Panigrahi
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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SELF DECLARATION

(AS PER ODISHA MISCELLANEOUS CERTIFICATE RULES,1984)

I SRI/SMT/MISS BIBEKANANDA PRUSTY AGED ABOUT 26 YEARS / DOB 1999-05-10, S/O, D/O,
W/O S/O-JAGANNATH PRUSTY OF AT-KANTAIKOLI,PO-KANCHURU, VILLAGE KANTAIKOLI,
PS-HINJILICUT, DIST- GANJAM, ODISHA DO HEREBY DECLARE THAT THE INFORMATION
GIVEN BY ME IN THIS APPLICATION FORM AND ITS SELF-ATTESTED ENCLOSURE IS TRUE TO
THE BEST OF MY KNOWLEDGE AND THE INFORMATION FURNISHED IS EXHAUSTIVE AND I
HAVE NOT SUPPRESSED ANY FACT. THAT I SOLELY RESPONSIBLE FOR THE ACCURACY OF
THE DECLARATION INFORMATION FURNISHED AND LIABLE FOR ACTION UNDER SECTION 199
AND 200 OF THE INDIAN PENAL CODE IN CASE OF WRONG DECLARATION AND
INFORMATION. ALSO, I AM WELL AWARE OF THE FACT THAT THE CERTIFICATE SHALL BE
SUMMARILY CANCELLED AND ALL THE BENEFITS AVAILED BY ME SHALL BE SUMMARILY
WITHDRAWN IN CASE OF WRONG DECLARATION AND INFORMATION.

CASTE DETAILS:

RELIGION: HINDU

CASTE: OBC

SUB CASTE / COMMUNITY: RANGANI

OCCUPATIONAL BACKGROUND: STUDENT

PURPOSE: FOR EMPLOYEEMENT PURPOSE

SIGNATURE OF THE APPLICANT

DATE: 22-07-2025

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