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
