Fillable Printable Application Form for a Certificate for Backward Classes
Fillable Printable Application Form for a Certificate for Backward Classes
Application Form for a Certificate for Backward Classes
Application Form for a Certificate for Backward Classes
To
__________________________________
__________________________________
__________________________________
Sir,
I r equest that a cer ti f icate be granted to me, as a per son belonging to Backwar d C l ass.
I gi ve bel ow the necessary par ticulars :—
1. Full Name of the Applicant :
( in block letters )
2. Date of Birth :
3. Complete Residenti al Address
a) Present :
b) Permanent :
4. R eligion :
5. Caste :
6. Sub-Caste :
7. Occupational Group :
8. Name of Father :
9. Name of Mother :
10. Name of Husband :
11. Status of Parent(s)/Husband :
Father Mother Husband
A) Constitut ional Posts :
I Designation :
B) Government Service :
i) Service ( Central State ) :
ii ) Designation :
iii) Scale of pay, including classif ication, if any :
iv) Date of Appointment to the Post :
v) Age at the t ime of promotion
to Class I post ( if appl icable ) :
12. Employment in Internati onal Organization e. g.
UN. UNICE F, WH O :
i) Name of Organization :
ii) Designation :
iii) Period of Service :
( indicate date from ……… to)
(2)
Father Mother Husband
III)
Death/Permanent Incapaci tation
( Om it i f not applicable )
i) Date of death / permanent incapacitation
putting an officer out service :
ii) Details of permanent incapacitation :
C) E m ployment in Publ ic Sector Undertakings
under Govt. of India. / under Govt. of West Bengal etc. :
i) Name of Organisation :
ii) Designation :
ii i) Date of Appointment to the post :
D) Armed Forces including Paramilitary Forces
(T his will not include persons holding Civil posts) :
i) Designation :
ii) Scal e of Pay :
E) Professional Class (other than those covered in it em Nos.
B & C and t hose engaged in trade, business and industry)
i) Occupation / Profession :
F) PROP ERTY O W NE RS
l) Agricultural Land Holding : Owned by Mother, Father & Minor Children.
i) Location :
ii) Size of holding :
iii) a) Irr igated :
(Type of Irrigated land)
i)
ii)
iii)
b) Unirr igated
T o be ce r t i f ied by
Di s t r i ct R eve nue
Officer not l ower
than the rank of
BL & LRO
iv) Percentage of Irrigated land holding to statutory ceiling limit under State
Land Ceiling Laws.
v) I f land holding is both irrig ated / unirrig anted, total irrigated land holding on
the basis of conversion formula in State Land Ceiling Law.
vi) Pe rcentage of Total irrigated land holding to statutory ce iling limit as per
(iv).
(3)
II) Plantation :
i) Crops/Fruit :
ii) Location :
iii) Area of Plantation :
III) Vacant land and /or buil dings in ur ban areas or urban agglomeration :
i ) Location of Prop e rty :
ii) Detail of Property :
iii) Use to which it is put :
G) Income / Wealth :
i) Annual family income from all sour ces :
(excluding salaries and i ncome from agr icultural land)
ii) Whether Tax payer : (Yes/ No)
(If yes, a copy of the last three years return be furnished)
iii) Whether cover ed in Weal th Tax Act : (Yes/ No)
(If so, furnish details)
H) Any other Remarks :
I) I certify that the above said particulars are true to best of my knowledge and belief and that I do not
belong to the categories of persons to when reservation shall not apply as per provisions contained in the
schedule mentioned in the Order No 347 TW/EC dated 13/7/1994 of the S.C/T.W Department,
Government of West Bengal and am eligible to be considered for posts reserved for O.B.C.s. In the event
of any information being found false or incorrect or ineligibility being detected before or after the
selectional. I undertake that my candidature/appointment is liable to be cancelled and I shall be liable to
be such further action as my be provide d under the law and / or Rules.
Yours faithfully,
Place _________________
Date ___________ ______ Signatu re of Candidat e
………………………………………..…
………………………………………..…
Received an applicat io n from Sri/Smt./ Kumari ______ _____ ____________ ____________ _____ _______
_________________________ of Village / Ward No __________________________________ under P.S
_________________________.
Signature
BDO __________________________ Block / OBC Cell.
