The form of certificate to be produced by Scheduled Castel Scheduled Tribe candidatesapplying for appointment to posts under the Government of lndia.

'This is to certify that Shri/Sh rimati/Ku ma rir

son/daughter* of . ..................... ... of village/town

in District/Division * ................. of the State/Union Territory*

;:;:";",;.;.,,:;;;,;:J,,"j;:,:::;;.;- cas'ie/'iribe*which

@ the Constltution (Scheduled Castes) Order, 1950

@ the Constitution (Scheduled Tribes) Order, 1950

@ the Constitutlon (Scheduled Castes) iUnion Territories) Order, 1951

@.the Constitution (Scheduled Tribes) (Union Territories) O.der, 1951

las amended by the Scheduled Castes and Scheduled Tribes List (Modification) Order, 1955; theBombay Reor8anisation Act, 1960; the Punjab Reorganisation Act, 1966; the State of Himachal

Pradesh Act, 1970; and the No.th Eastern Areas (Reorganisation) Act, 1971 and the Scheduled

Castes and Scheduled Tribes Orders {Amendment) Act, 1976, the State of Mizoram Act, 1986 the

State of Arunachal Pradesh Act, 1986 and the Goa, Daman and Diu (Reorganisation) Act, 1987.1

@ the Constitution (.lammu and Kashmir) Scheduled Caste Order, 1956

@ the Constitution (Andaman and Nicobar lslands) Scheduled Tribes Order, 1959 as amendedby the Scheduled Castes and Scheduled Tribes Order (Amendment) Act, 1976.

@ the Constitution (Dadra and Nagar Haveli) Scheduled Castes Order,1952.

@ the Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order,1962.

@ the Constitution (Pondicherry) Scheduled Castes Order, 1964.

@ the Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967.

@ the Constitution (Goa, Daman and Diu) Scheduled Castes Order, L968.

@ the Constitution (Goa, Daman and Diu)Scheduled Tribes Order, 1968.

@ theconstitution (Nagaland) Scheduled Tribes Order, 1970.

@ the Constitution {sikkim) Scheduled Castes Order, 1978 @ the Constitution (Sikkim)

Scheduled Tribes Order, L978.

@ the Constitution (Jammu & Kashmir) Scheduled Tribes Order, 1989

@ the Constitution (SC) Order (Amendment) Act, 1990.

@ the Constitution (5T) Order (Amendment) Act, 1991.

@ the Constitution (ST) Order (Second Amendment) Act, 1991.

(a the Scheduled Castes and Scheduled Tribes Orders (Amendment) Act,2002.

@ the Constitution (5cheduled Castes) Order (Amendment) Act, 2002.

@ the Constitution (Scheduled Castes and Scheduled Tribes) Orders (Amendment)Act, 2002.

@ the Constitution (Scheduled Castes) Orders (Second Amerdment) Act, 2002 @

%2.ApplicableinthecaseofScheduledCastes/ScheduIedTribespersonsrvhohavemigratedfrom one State/Union Territory Administration to another'

This certificate is issued on the basis of the scheduled casles/ scheduled Tribes certificate*

issuedtoshri/Shrimati*.''Father/motherofShri/Shrimati/Kumari*

o,ii''.iiori',."; . .. .

Territory*............Tribet which is recognised a

Territory.......................issue

oi villa gel

..... who belongs

d uled Caste/Sch

tn

... of the state/u nion

to the .................. ... ........ .............caste/

eduled Tribe* in the State/Union....... ...... dated. .... ..... ..

town*.......

, "

t.n"d by the

% 3. Sh rilsh rimati/Ku m ari+ .... .. . ...,...

ordinarily reside(s) in village/. town*......D ist r ict/D ivis ion *

. an d/or* his/her* {amilY

'. ' ' .'.. ' '..',...' ' ' '.'''. ., ,., (Jl

of the State/Union Terrrtoryl of

Signature...

**Designation.

...... State/U nion Territory * . .. ...., . ..

(With Seal of Office)

Place:......,..

Date: ..........

*Please delete the words which are not applicable

@ Please quote specific Presidential order.

% Delete the paragraph which is not applicable.

NOTE: The term "Ordinarily reside(s)" used here will have the same meaninS as in Section 20 of

the Representation of the People Act, 1950.

**List of authorities empowered to issue Scheduled caste/scheduled Tribe/oBC certiflcates.

(i) District Magistrate/Additional Distrlct Magistrate/ CollectorlDep uty

commiss;oner/Add ition al Deputy com missioner/Deputy collector/1st class stipendiary

Magistrate/...5ub-Divisional Magistrate/Ta luka Magistrate/ Executive M a gistrate/Ext ra

Assistant Commissioner. (... not below the rank of 1st Class Stlpendiary Magistrate)

(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/PresidencyMagistrate.

(iii) Revenue Officers not below the rank of Tehsildar.

(iv)Sub Divisional Officer of the area where the candidale andlor his family normally resides.

in District/Division * ......-.-.....,.. of the StatelUnion Territory*

;:";;.; ; . ;,.u*.,r. ,,, ,"o".llonu"o'n' commun;tv which :s

@Government of India, Ministry of Welfare Resolution No. 1.2011/68/93-BCC{C) dated 10thSeptember, 1993 published in the Gazette of lndia Extraordinary Part l, Section l, No. 186

dated the 13th september, 1993.

@covemment of lndia, Ministry of Welfare Resolut,on No. 12O1L/9/94-BCC dated 19-10-94,published in the Gazette of lndia Extraordinary Parl l, Section l, No. 163 dated 20-10-1994,

@covemment of lndia, Ministry oi Welfare Resolution No. 12011/7 /95-BCC dated 24-5-95,

published in the Gazette ol lndia Extraordinary Part l, Section l, No. 88 dated 25-5-1995,

@Government of lndia, Ministry of Welfare Resolution No. 12011/96/94-8CC dated 9th

March, 1996 published in Gazette of lndia Extraordinary Part l, Section I, No, 60 dated 11th

M a.ch,1996.

@Gove.nment of lndia, Ministry of Welfare Resolution No. 12011/44196-SCC dated 6th

December, 1996 published in the Gazette of lndia Extraordinary Part l, Section l, No.210dated 11th December,1996.

@Government of lndia, Ministry of Welfare Resolution No. 12011/13/97 -BCC dated 3rd

December, 1997 published :n the Gazette of lndia Extraordinary Part-1, Section-1, No. 239

dated the 17th December, 1997.

@Govemment o, lndia, Ministry of Welfare Resolution No. 12O11/99/94-BCC dated the 11th

December, 1997 published in the Gazelte of lndia Extraordinary Part l, Section l, No.236

dated the 12th December,1997.

@Government of lndia, Manistry of Social Justice and Empowerment Resolution No'

12011158198-SCC dared the 27th october, 1999 published in the Gazette of lndia

Extraordinary Part l, Section I, No.241daEd the th october, 1999

@Government oi lndia, Ministry o{ SocialJustice and Empowerment Resolution No'

f2ov88l98-gCC dated the 6th December, 1999 published in the Gazette oJ lndia

Extraordinary Pa.t l, Section l, No.270 date*lhe th December, 1999.

@Government of lndia, Ministry of Social Justice and impowerment Resolution No.

LZOltl36lgg-7CC dated the 4th April, 2000 pu3lished in the Gazette of lndia Extraordinary Part

l, Section l, No. Tl dated the 4th April,2000.

@Government of lndia, Ministry of Social Justice and Empowerment Resolution No.

uotl,lq*lgg-gcc dated the 21st september, 2000 published in the Gazette of lndia

Extraordinary Parl l, Section l, No. 210 dated the 21st September, 2000

@Government of lndia, Ministry of Soc:alJustice and Empowerment Resolutlon No'

12}15lg l2ooa-scc dated the 6th September, 2001 pubiished in the Gazette of lndia

Extraordinary Part l, Section l, No.246 dated the 5th September, 2001'

@Governmentoflndia'MinistryofSociaIJusticeandEmpowermentResolutionNo.lZOnlllZOOt BCC dated 19th June, 2003 published in the cazette of lnd;a Extraordinary Part l,

Section l, No, 151 dated 20th June,2003'

@Government of lndia, Ministry of Social Justice and Empowerment Resolution No

1201,114120O2-Bcc dated 13th January, 2004 published in the Gazette of India Extraordinary'

Part I, Sect,on l, No.9 daled 13th January, 2004.

@Governmert of lndia, Ministry of Social Justice and Empowerment Resolution No'

The Jorm of certificate to be produced by Other Backward classes candidates applying forappointment to posts under the Government of lndia.

'This is to certify that Shri/Sh rimatilKuma ri*......, ,.......,...,..

I2Onlgl2OO4-AaC dated 16th lanuary, 2006 published in the Gazette of lndia Extraordinary,

Par: l, Section l, No. 10 dated 16th January, 2006.

@Government of lndia, Ministry of social Justice and Empowerment Resolution No.

L2O1:1l1412OO4-SCC dated 12th March, 2007 published in the Gazette of lndia Fxtraordinary,

Part l, Section l, No. 67 dated 12th March,2007.

@Goverrment of lndia, Ministry of social Justice and Empowerment Resolution No.

12015 /2l2OO7 -BCC daled 18ih August,2010 published in the 6azette of lndia Extraordinary,

Part l, Section l, No. 232 dated 18th August,2010.

@Governmenl of lndia, M:n;stry of Social Justice and Empowerment Resolution No'

7203"51212A07 -SCC dared 1.1"$ October,2010 published in the Gazetle of lndia [xtraordinary,

Part l, Section l, No. 274 dated 12!h October,2010,

@Government of lndia, Ministry of Social lustice and Empowerment Resolutjon No.

12O15lL5I2AO9-BCC dated 16 ,.lune, 2011 published in the Gazette of India [xtraordinary, Part

l, section l, No. L23 dated 16th lune, 2011.

@Government of lndia, Mlnistry of Social Justice and Empowerment Resolution No.

\2A75 /B/ZAfi-Bc- ll datecl 8th December, 2011 published in the Gazette oi lndia Extraordinary,

Part l, Section l, No. 257 dated 08th December, 2011.

Sh ri/Shrimati/Kuma ri * and/ or" his/her* family ordinarily

reside(s) in village/town*...... of District/)ivision* of the

State/Union -Ierritory * of..................................................This is also to certi{y that helshe* does

not belong to the persons/ sections* (Creamy Layer) mentioned in column 3 of the Schedule io the

6ove:'nme:Tt of lndia, Department of Personnel & lraining O.M. No. 36012/22l93-Estt.{SCT) dated

8-9-1993, O.M. No. 36033/3/2004-Estt. ires.)dated 9th March, 2004, O.M. 3503 3/3/2004- Eslt,

(Res) dated 14-10-2008 and oM No. 35033/1/2013-Estr.(Res.) dared 27.5.2013.

Signature...

* * Designation. (With seal of office)

Place

Da te.

Note 1: The fo.mat of undertaking to be furnished along with the DAF bv other EackwarC Class

candidates applying for appointment to post under the Government of lndia, is available as

Annexure Vl.Note 2: Creamy layer clause in respect of oBC candidates rnust be as per OM No.

36033/1/2013- Estt. (Res. ) dared 27.5.20L3Note: The lerm "ordinariiy reside( s)" used here will have the same meaning as in Section 20 ofthe Represenaation of the People Acl, 1950.*Please delete the words which are not applicable.@St.ike out whichever is not applicable.**List of authorities empowered to issue Scheduled Caste/Scheduled Tribe/OBC Certificates.(i) D:str;ct M ag;strate/Additio na I D:strict l\4agistrate/ CollectorlDe puty

Commissioner/Additional Deputy Com m issione r/Deputy Collector/1st Class StipendiaryMagistrate/... Sub-Divisional Magistrate/Ta luka M agistrate/ !xecutive Magistra:elExtraAssistant Commissioner. (...not below the rank of 1st Class Stjpendia.y Magistrate).

(ii) Chief Presidency Magistrate/AdditionalChief Presidency M agistrate/PresidencyM agistrate.

(iiD Revenue Olficers not below the rank of'aehs;ldar. (iv) Sub D;visionalOfficer ofthearea where the candidate and/or his family normally resides.

FOR OBC(Non -Creamv Laver) CANDIDATES.

"1,...,...................... son/daughter of Shri ......................,................Resident

of village/town/ city....................,...,.......distr'ct...............sta:e............,.........hereby declare

that I belong to the,...............................commu.1ity which is recognized as a backward

class by the Government of lndia {or the purpose of reservation in services as per

o.ders contained in Department of Personnel and Training Office Memorandum No.

36}72/22/93-tstt. (scT),dated 8.9.1993. tt is also declared that I do not betong to

persons/sections {Creamy layer) mentioned in Column 3 of the Schedule to the above

referred Office Memorandum, dated 8.9.1993, O.M. No. 36033/312004-Estt.{Res),

dated 9.3.2004, O.M. No. 36033l3lZOO4-Estt.(Res), dated 14.10.2008, O.M. No.

36033/7/2}13-Estt. (Res) dated 27 /alZ0L3 and OM No.36033/1/2013-Estt. {Res. ) dated

13.09.20t7 .

Signature

N ame:

Certificale No. .....

This is certified that Shrii Sint./Kum

.... is suffering from pennanent disabili:y offollorvingcaaegory:

A, tocomotor or cerebral palsy:

(i) BL-Bolh legs allected but not arms( ii) BA-Both arms affected {a) lmpaired reach

(b) Weakness of grip

(c) Ataxic(iii) BLA-Both legs and both a:ms allec:ed(iv) OL--One leg affected (right or lell) (a) lmpaired reach

(b) Weakness of grip

(c) Ataxic

(v) OA- One arm aflected (a) Impaired reach

(d) Weakness olgrip(e) Ataxic

(vi) BH-Stiffback and hips (cannot sil or stoop)(vii) MW-Muscular rveakness and limited physical endurance

B. Blindness or Lorv Vision :

(i) B-Blind( ii) PB-Partially Blind

C, Hearing Impairment :

(i) D-Deaf( ii) PD-Par"tialty Deai

(Delete the category, whichever is not applicable)

Recent photograph of

t!e candidate shorving

the d isability duly

attested by the

Chairperson of the

Medicai Board

NAMI AND ADDRESS OF'''HE INSTITUTE/HOSPITAL

DISABILITY CERTIFICATE

Date ................................

2. This condition is progressive/ non-progressive/ likell.to improve/ noi likely to improve

Re-assessment olthis case is not recommended/ is recommended a{ler a period of..-......-........years ............,,........mon1hs*.

3. Percentage ofdisability in hislher case is .

4. $i,smt.'Krin . meets the lollowing physical Lequirements

.... pcl ccnt.

lbr di:charge ofhis/ hcr dLtries :-(i) F Can perform rvork by manipularing rvith fingers.

(ii) PP{an perlonn work by pulling and pushing.

(iii) L-Can perlornr w.ork by lifting.

(iv) KC-Can perlonr rvork by kneeling and crouching

(v) B-Can perlorm wo:k by bending.

(vi) S-Can perfbrm r.vork b1, si:ring.

(vii) ST{an pertbnrr rvork bl standing,

(viii) W{an perform rvork by *,alking.

(ix) SE Can perfbrm work by seeing.

(x) H{an perform work bi, hearing/speaking.

(xi) RW{an perlorm rvork by r.eading and rvriting.

Yes,No

Yes,No

Yes,No

Yes,{rio

Ye srlrlo

YesAlo

YesNo

YesAo

YesNo

YeslN.'o

Yes,,T{o

(Dr.....,..

MemberMe dical Board

*(Delele rvhiciever is not applicable)

) (Dr ) (DrMemberMedical Board

,,'','',,,',''.',,,'' )

Chairperson

MedicalSoarC

Counle r.signed by the A.:[edictSuperintendent/C l,l)i Heud of

Hospita! ht ir h Seoll