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Fill All The Details in The Block Letters: Certificate

This document is an application form for a Socially and Educationally Backward Caste Certificate. It requests personal details of the applicant such as name, gender, date of birth, contact information, caste, and purpose of the application. It also requests employment, income, property, and wealth details of the applicant's father, mother, and spouse to determine the applicant's eligibility for the certificate. The applicant must sign declaring the information provided is true. The processing time for the application is estimated to be 30 working days.

Uploaded by

Neelakanta Kalla
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
98 views

Fill All The Details in The Block Letters: Certificate

This document is an application form for a Socially and Educationally Backward Caste Certificate. It requests personal details of the applicant such as name, gender, date of birth, contact information, caste, and purpose of the application. It also requests employment, income, property, and wealth details of the applicant's father, mother, and spouse to determine the applicant's eligibility for the certificate. The applicant must sign declaring the information provided is true. The processing time for the application is estimated to be 30 working days.

Uploaded by

Neelakanta Kalla
Copyright
© Attribution Non-Commercial (BY-NC)
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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Court Fee Stamp as required

APPLICATION FORM FOR ISSUANCE OF

SOCIALLY AND EDUCATIONALLY BACKWORD CASTE CERTIFICATE


(Fields marked * are mandatory)

Paste Applicant
Photo

Service Payment Details :

1.Service Charges of the kiosk Operator per Unit =


2.Printing Charges per unit =
3.Scanning Charges per unit =
4.The Government fees per unit =
5.Degs Charges fee per unit =

8.00
10.00
5.00
30.00
2.00
____
Total 55.00 .
(The amount may vary based on no of printing and scaning page counts)
Documents Required
Mandatory Documents
Supporting Documents

Applicants signatutre / Thumb Impression


1. RoR
2. Self Declaration
3. Land Pass Book
4. Any other document in support/claim

Delivery Time Lines ; Estimated Timelines To Process The Application (Expected Date of Delivery) : 30 working Days

Fill all the details in the block letters


Personal Details
Applicant Name*
Gender*

:- ___________________ ___________________ ___________________


:- ___________________
Marital Status*:- ___________________

Date of Birth*

:- ___________________

Parents Details
Father Name*
Mother Name*

:- ___________________ ___________________ ___________________

Age*

:- ___________________

:- ___________________ ___________________ _______________


Spouse Details
Spouse Name*
Relation With Applicant*
Contact Details
Phone No
Email

Permanent Address :Permanent Address


District *
Tahsil *
Block *
GP/ULB

House No/Street Name


Police Station *
Submitter Details

:- ___________________ ___________________ ___________________


:- ___________________
:- ___________________
:- ___________________
Urban

:- __________________

Rural

:- _____________________
Sub Division *
:- ___________________________
:- __________________
RI Circle *
:- ________________________
:- ____________________
:- ______________
Village / Ward* :- _____________________________________________
:- ________________________ Post Office
:- _________________________
:- __________________
Pin
:- ________________________

Is applicant and submitter are same? *


Submitter's Name*
Relation With Applicant*

Mobile No

Yes

No

:- ___________________ ___________________ ___________________


:- _______________________________________

Present Address :-

Urban

Is Present Address Same as Permanent Address?


(If "No" please fill the Present address given below)
Permanent Address
District *
Tahsil *
Block *

Rural
Yes

No

:- _____________________
Sub Division *
:- ___________________________
:- __________________
RI Circle *
:- ________________________
:- ____________________
:- ______________
Village / Ward* :- _____________________________________________
:- ________________________ Post Office
:- _________________________
:- __________________
Pin
:- ________________________

GP/ULB

House No/Street Name


Police Station *

Caste Details :Religion *


:-__________________________________
Caste* _____________________________________
Sub Caste/Community :- _________________________________ Occupational Background :________________________

Purpose :-

___________________________________________________________________________________

Father Mother& Spouse Other Details


Please select the respective relation (Father / Mother / Spouse) to fill up the details

Father
Constitutional Post:
Designation :
Government Servic
Service(Central/State):

_________________

Mother

Spouse

_______________ ________________

Designation:

__________________ ________________ ___________________

Scale of Pay, including classification if any

__________________ _________________ ___________________

Date of appointment to the Post:

__________________ __________________ __________________

Age at the time of promotion to the class-1post:

___________________ __________________ ___________________

Employment of International Organization


Name of Organization:

__________________ ___________________ __________________

Designation:

___________________ ___________________ _________________

Period of Service Form:

___________________

Period of Service To;

_______________ _____________________ ___________________

___________________ _________________

Death/Permanent In-capacitation (Putting an officer out of Service):


Date of Death/Permanent In-capacitation:

__________________ ___________________ ____________________

Details of permanent In-capacitation;

____________________ __________________ ___________________

Employment in public Sector Undertaking


Name of organization;

_____________________ __________________ ____________________

Designation:

_____________________ ___________________ ___________________

Date of appointment to the post:

____________________ ____________________ ___________________

Armed Forces including Para-military forces


Designation:

_____________________ ___________________ ____________________

Scale of pay;

______________________ ___________________ ___________________

Professional Class(Please indicate whether engaged in Trade, Business and Industry)


Applicants Occupation/Profession:

_____________________ _____________________ __________________

Property Owners
Agricultural land holding (owned by mother, father and minor children)
Location:

_______________________ _____________________ __________________

Size of holding (Area):

_______________________ ______________________ _________________

Irrigated (type of Irrigated Land)


I

_____________________ _______________________ ___________________

II

_____________________ _______________________ ___________________

III

______________________ ______________________ ___________________

Unirrigated
IV. Percentage of irrigated landholding to statutory ceiling limit
Under state land ceiling law:

______________________ ________________________ __________________

V. If land holding is both irrigated/un-irrigated total irrigated land


holding on the basis of conversion formula under state land celing law:________________ _________________ ________________
VI. Percentage of total irrigated land holding to statutory ceiling limits as per (V):____________ ______________ _______________
Plantation
Crops/Fruits:

______________________ ______________________ ____________________

Location:

______________________ ______________________ ____________________

Area of Plantation:

______________________ ______________________ ____________________

Vacant land and buildings in Urban areas or Urban Agglomeration


Location of property:

_____________________ _______________________ _____________________

Details of property:

______________________ _____________________ ______________________

Use to which it is put:

_______________________ ____________________ ______________________

Income /Wealth
Annual family income from all Sources (including salaries &
Income from agriculture land):

_______________________ _________________________ __________________

Whether Tax Payer (if yes, a copy of the last 3 returns be furnished):__________________ ____________________ _______________
Whether covered in wealth tax act(if yes,Furnish details): ________________________ _____________________ ________________
Wealth Tax Details:

________________________ _____________________ __________________

Any other remarks;

_________________________________________________________________

I, Shri / Smt ....Son of / Daughter of / Wife of .


resident of village ... P.S. .. District ... and I certify that the above said
particulars are true to the best of my knowledge and belief that I do not belong to the Creamy Layer of S.E.B.C/O.B.Cs. and eligible to
be considered for the posts reserved for S.E.B.C/O.B.Cs. In the event of any information being found false or incorrect, or ineligibility
being detected before or after the selection, I understand that my candidature/appointment is liable to be cancelled and I shall be
liable to such further actions as may be provided under the law and/or rules.

Yes

No

Signature of the applicant

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