I
S1 ..No of 20 Annexure - B
APPLICATION FOR A CERTIFICATE FOR ILLEGIBILITY FOR
RESERVATION OF JOBS , FOR THE OTHER BACKWARD CLASSES
IN CIVIL POSTS AND SERVICES UNDER'OVERNMENT OF INDIA
To
The Deputy Commissioner
Imphal East District,Manipur.
Sir
I request that a certificate in respect of reservation for other backward
classes in Civil post and services under Govemment;of India be granted to me.
1. Full name of the applicant
(in the Block Letter)
2. Date of Birth
3. Complete residential Address:
a) Present
b) Permanent
4. Religions
5. Caste
Sub -Caste
7. Occupational Group
8. Serial number of Caste
in the central list of OBCs
9. Name of the Father
10. Name of the Mother
11. Name of the Husband
12, Status of Parent(s)/Husband
Father Mother
I) A. Constitutional Posts
i) Designation
B) Government Services :
i) Service(Central/State):
ii) Designation
iii) Scale of pay including classification ,,if any :
iv) Date of appointment to the post
v) Age at the time of promotion
to Class- I Post( if applicable)
II Employment in International/ Organisation
e.g. UN,UNICEF, WHO
1) Name of Organisation
ii) Designation
ii) Period of Service
(including date from to-
III Death I Permanent incapacitation (omit if not applicable)
i) Dated of death / Permanent incapacitation :
pulling of Officer out of service
ii) Details of Permanent Incapacitation
Contd 2/-
C) Employment in the public sector undertaking etc.
i) Name of the Organisation
. :
ii) Designation
iii) Date of appoitment of the post :
D) Armed forces including Para-Millitary Forces
This v6Il not includes persons holding civil post
i) Designation
ii) Scale of pay
(E) Professional Class
;. (Other than three concerned in item No S & S) and these engaged in trade business and industries.
Property Owners :
I) Agriculture land Holding, Owned by Mother,Father and Minor Children
ii) Location
iii) Size holding :
iv) a) Irrigation ( type of irragated land)
i)
ii)
iii)
(b) Unirrigated land :
iv) Percentage of Irrigated land holding
to statutory ceiling limit under
State land ceiling laws.
v) If and holding is both irrigated/
unirrigated total irrigated land
holding on the basis of conversion
formula in state land ceiling law
vi) Percentage of total irrigated land
holding to statutory ceiling limit
as per (iv)
II) Plantation
i) Crops/Fruits :
ii) Location
iii) Area of Platation
iv)• Vacant Land and/or building in Urban areas of Urban agglomeration
i) Location of Property :
ii) Details of Property :
iii) Use of which it is put :
Contd 3/-
IV) Income/Wealth
i) Annual Family income from all sources
excluding salaries and information from
agricultural land )
ii) Whether Tax payer (Yes/No)
(If Yes , a copy of the last three years return
be furnished)
iii) Whether covered in wealth Tax Act : Yes / No.
13, Any other remarks
14. I certify that the above said particulars are true to the best of my knowledge and belief and that I
do not belong to the creamy layer of OBCs and eligible to be considered for posts reserved for OBCs . In
event of my information being found false or incorrect , or in-eligibility being detected before or after the
selection. I understand that my candidate appointment is liable to be cancelled and I shall be liable to such
further action as , may be provided under the law and or Rules.
Place: Signature of the candidate
Date :
I have personality and physically verified all the information furnished by the applicant and found
correct,
Sub -Deputy Collector
The above person / the applicant does not belong to the category of persons mention in Co1.3 of the
Schedule to the office memorandum NO.36033/3/2004-Estt(Res.) Government of India Ministry of Pqr-
sonnel, 09-03-2004, on the subject.
Reservation for other Backward classes in Civil Pests and Services under the Government of India
Regards.
Sub - Divisional Officer
"TO WHOM IT MAY CONCERN"
(LAND HOLDIN( CERTIFICATE)
This is to certify that the land(s) under Patta No.
Covered by C.S. Dag No. having an area of
is recorded in the name of Shri/Smt
S/o, D/o, W/o,
a resident of
He/ She is not related to me.
Signature of the Issuing
Officer (with seal)
"TO WHOM IT MAY CONCERN"
This is to certify that Shri /Smt/Km.
and Smt 1 Mrs who is/are the
parents(Father/Mother) of Shri/Smt/Km/Miss
is/are not employed in any central/state govt. services
or any other Public sector undertaking or private firms.
They/he/she is/are empoyed/unemployed/self employed as
and respectively.
The annual income of both parents from all sources is Rs. per
annum.
Signature
Name
Date : Designation :
Place (with seal)
