migrated from one State / Union Territory Administration.
This certificate is issued on the basis of the Scheduled Castes / Scheduled Tribes*
Certificate issued to Shri. / Smt. / Kumari*
_________________________________________Father /Mother* of Sri / Smt. /
Kumari*____________________________________________________of village /
town ______________________in District/Division*____________________of the
State/Union Territory*_________________________________ who belong to
the______________________ Caste / Tribe* which is recognized as a Scheduled
Caste/Scheduled Tribe* in the State/Union Territory* issued by the
____________________________________[Name of the authority] vide their order
No. ___________________________ dated _______________________.
3.Shri/Smt/Kumari*____________________________________________and/or*
his/her* family ordinarily reside(s) in village/town*__________________________
of____________________ District / Division* of the State / Union Territory* of
_____________________
Signature _____________________
Designation ___________________
Place: [With seal of Office]
Date: State/Union Territory
Note: The term "Ordinarily resides" used here will have the same meaning as in Section 20
of the Representation of the Peoples Act, 1950.
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* Please delete the words which are not applicable.
# Delete the paragraph which is not applicable.
List of authorities empowered to issue Caste / Tribe Certificates:
1. District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner /
Additional Deputy Commissioner / Deputy Collector/I Class Stipendiary Magistrate / Sub-
Divisional Magistrate / Extra-Asst. Commissioner / Taluka Magistrate / Executive Magistrate.
2. Chief Presidency Magistrate/ Additional Chief Presidency Magistrate / presidency
Magistrate.
3. Revenue Officer not below the rank of Tehsildar.
4. Sub-Divisional Officers of the area where the candidate and / or his family normally
resides.
5. Administrator/Secretary to Administrator/Development Officer Lakshadweep).
Note: The Certificate is subject to amendment/modific
FORM OF CERTIFICATE TO BE PRODUCED BY
OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT
TO POSTS UNDER THE GOVERNMENT OF INDIA
This is to certify that Sri/Smt./ Kumari
________________________________________________ son/daughter of
__________________________________ of village/Town
____________________________District/Division _______________ in the State/
Union Territory________________________ belongs to the
______________________________community which is recognized as a backward
class under the Government of India, Ministry of Social Justice and Empowerment’s
Resolution No. __________________ dated ___________*. Shri/Smt./Kumari
____________________and/or his/her family ordinarily reside(s) in the
______________________District/Division of the
__________________________State/Union Territory. This is also to certify that he/she
does not belong to the persons /sections (Creamy Layer) mentioned in column 3 of the
Schedule to the Government of India, Department of Personnel & Training OM
No.36012/22/93- Estt.[SCT], dated 8-9-1993
Dated:
District Magistrate Deputy Commissioner etc.
Seal
* - the authority issuing the certificate may have to mention the details of Resolution of
Government of India, in which the caste of the candidate is mentioned as OBC.
**- As amended from time to time.
Note: - The term “Ordinarily” used here will have the same meaning as in Section 20 of
the Representation of the People Act, 1950.
The Prescribed proforma shall be subject to amendment from time to time as per
Government of India Guidelines. 21
amputation or complete permanent paralysis of limbs and in cases of
blindness) (Prescribed proforma subject to amendment from time to time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)
Certificate No. : Date :
This is to certify that I have carefully examined
Shri/Smt./Kum._________________________________________________________
____son/wife/daughter of Shri
___________________________________________________ Date of Birth (DD / MM
/ YY) ____ ____ ____ Age ________ years, male/female
Registration No.
__________________________ permanent resident of House
No.______________________
Ward/Village/Street___________________________________________ Post Office
_______________________________District __________ State ____________,
whose photograph is affixed above, and am satisfied that:
(A) he/she is a case of:
Locomotor disability
Blindness
(Please tick as applicable)
(B) The diagnosis in his/her case is _________
(A) He/ She has ______________% (in figure) ________________________ percent (in
words) permanent physical impairment/blindness in relation to his/her _________ (part
of body) as per guidelines (to be specified)
The applicant has submitted the following documents as proof of residence:-
2. Nature of
Document
Date of Issue Details of authority issuing
certificate
(Signature and Seal of Authorized Signatory of notified Medical
Authority)
Recent PP size
Attested
Photograph
(Showing face
only) of the
person with
disability
Signature/Thumb
impression of the
person in whose
favor disability