ANNEXURE - B

APPLICATION FORM FOR CERTIFICATE OF ELIGIBILITY FOR RESERVATION

OF JOBS FOR THE OTHER BACKWARD CLASSES IN CIVIL POSTS AND

SERVICES UNDERCENTRAL GOVT. OF INDIA

Cost : ` 1/-

(PTO)

Sir,

I request you a CERTIFICATE in respect of Reservation for BACKWARD CLASSES in civil POSTS &

SERVICES under Government of India be granted to me.

I. Given below of the necessary particulars

1. Full name of the Applicant : _________________________________________________________________________

(In Block Letters)

2. Gender : _____________________ 3. Date of Birth : ________________________________

4. Complete Resident Address : _________________________________________________________________________

a) PERMANENT

D.No : __________________ Locality : _______________________ Village : ______________________________

Mandal : _________________________ District : ____________________________ Pincode : ________________

b) PRESENT (Postal Address)

D.No : __________________ Locality : _______________________ Village : ______________________________

Mandal : _________________________ District : ____________________________ Pincode : ________________

5. Religion : ______________________ 6. Caste : __________________________ 7. Sub-Caste : _________________

8. Issued Caste Certificate In Past : YES / NO 9. Education Certificate Contains Caste : YES / NO

10. Occupation Group : ________________________________________________________________________________

11. SERIAL NUMBER of the Caste in the CENTRAL LIST OF OBCs : _________________________________________

12. Name of the Father : _______________________________________________________________________________

13. Name of the Mother : ______________________________________________________________________________

14. Name of the Husband : _____________________________________________________________________________

15. Status of the Parents(S) / Husband : Father/Husband Mother/wife

a) Constitutional Posts : ___________________________ b) Designation : __________________________________

c) i) Services: CENTRAL / STATE : _________________________

ii) Designation : ______________________________ iii) Scale of Pay, including : _____________________________

Clarification if any : ___________________________ iv) Date of Appointment of Post : ________________________

v) Age of the time of Promotion : _____________________to Class I post (if applicable) : _______________________

II. EMPLOYMENT IN INTERNATIONAL ORGANIDATION E.G., U.N., UNICEF, WHO

i) Name of the Organization : ____________________________________ ii) Designation : ________________________

iii) Period of Service (Indicate Date) : FROM__________________________ TO _____________________________

III. A. DEATH / PERMENT INCAPACITION (OMIT IF NOT APPLICABLE)

i. Date of death / Permanent Incapacitation putting an Officer Out of Service : ________________________________

ii. Details of permanent incapacitation : _______________________________________________________________

B. EMPLOYMENT IN PUBLIC SECTOR UNDERTAKING ETC.,

i) Name of the Organization : __________________________________ ii) Designation : _______________________

iii. Date of appointment to the Post :___________________________________

C. ARMED FORCES INCLUDING PARA MILITARY FORCES

(THIS WILL NOT INCLUDE PERSONS HOLDING CIVIL POSTS)

i. Designation : ____________________________________ ii. Scale of Pay : ________________________________

D. PROFESSIONAL CLASS (OTHER THAN THOSE COVERED IN THE ITEM NOS. B&C AND

THOSE ENGAGED IN TRADE, BUSINESS AND INDUSTRY)

i. Occupation / Profession : ________________________________________________________________________

E. PROPERTY OWNERS:

I. Agricultural land holding owned by mother / father and minor Children : ___________________________________

ii. Location : ___________________________________ iii. Size of holding : ________________________________

iv. a) IRRIGATED (TYPE OF IRRIGATION LAND)

I)

ii)

iii)

b) UNIRRIGATED

iv) Percentage of Irrigated Land holding to statutory ceiling limit : _______________________________________

under State Land Ceiling Land

v) If land holding is both irrigated / unirrigated total irrigated land : ______________________________________

holding on the basis of conversion formula in State Land Ceiling

vi) Percentage of total irrigated land holding to : ______________________________________________________

statutory ceiling limit as per (vi)

TO BE CERTIFIED DISTRCT REVENUE OFFICER NOT LOWER THAN

MANDAL REVENUE OFFCIER / TAHSILDAR

II. PLANTATION

i. Crops / Fruits : _________________________ ii. Location : _________________________________________

iii. Area of Plantation : __________________________________________

F. III. VACANT LAND AND / OR BUILDING IN URBAN AREA OF URBAN AGGLEMERATION

i. Location of Property : _____________________________ ii. Details of Property : _________________________

iii. Use to which it is put : _____________________________

G. INCOME / WEALTH

i. Annual Income from all Source (Family Income) : _____________________________________________________

(Excluding Salaries and Income from Agrl. Land)

ii. Whether Tax Paid : YES / NO

iii. Whether covered in Wealth Tax Act. (Yes / No) (If so furnish details) : _____________________________________

16. Family members consisting : _________________________________________________________________________

17. Purpose of Caste Certificate : ________________________________________________________________________

18. Ration Card Number : ________________________________ 19. Aadhar Number : ____________________________

20 Any other Information : _____________________________________________________________________________

21.I certify that the above said particulars are true to the best of my knowledge and belief and that I do not belongs to

CREAMY LAYER of OBCs and eligible to be considered for posts reserved for OBCs. In the event of any information

being found false or incorrect of ineligibility being detected before of after the selection. I understand that my

candidature appointment is liable to be cancelled and I shall be liable to such further action as may be provided under

law /or rules.

Yours faithfully,

Place: Signature of the Candidate

Dated:

Procedure (following to be enclosed) Contact Details

1) Application * Land Line Number:

2) Ration Card/Aadhar Card/EPIC Card # Mobile Number:

3) Applicant Father/Mother property particulars # E- Mail ID:

4) Applicant Father/Mother Employment

Particulars/Income Tax returns (for professionals) *

(*-mandatory #-any one of them)

SERVICES OFFERED

Sl. No. Service Service Level Service Charges (`)

1 Extract of Adangal / Pahani 15 Minutes * 25/-

2 Extract of ROR 1B 15 Minutes * 25/-

3 Copy of FMB 15 Minutes * 25/-

4 Copy of Village Map 5 Days 35/-

5 F-Line Petitions 30 Days 35/-

6 Sub-Division of Lands 30 Days 35/-

7 Mutation of Entries in Revenue Records 45 Days 35/-

8 Income Certificate 1st time - 7 days 2nd time & 35/-

thereafter - 15 minutes

9 Residence Certificate 1st time - 7 days 2nd time & 35/-

thereafter - 15 minutes

10 Integrated Certificate 1st time - 30 days 2nd time & 35/-

(Caste-Nativity-Date of Birth) thereafter - 15 minutes

11 OBC Caste Certificate 1st time - 30 days 2nd time & 35/-

thereafter - 15 minutes

12 EBC Certificate 1st time - 7 days 2nd time & 35/-

thereafter - 15 minutes

13 Agricultural Income Certificate 1st time - 7 days 2nd time & 35/-

thereafter - 15 minutes

14 No Earning Member Certificate 1st time - 7 days 2nd time & 35/-

thereafter - 15 minutes

15 Family Member Certificate 1st time - 7 days 2nd time & 35/-

(Social Security Schemes & thereafter - 15 minutes

Govt. Employees / Pensioners)

16 Issue of Encumbrance Certificate Same day, if submitted by 2 pm 25/-

17 Certified Copy of Registration Document 15 minutes 25/-

18 Money Lending License Fresh - 45 days Renewal - 30 days 35/-

19 Allopathic Medical Care Registration 90 Days 35/-

20 Apathbandhu Scheme 10 Days 35/-

21 NFBS Application 1 Week 35/-

22 No Objection Certificate (Lands) 30 Days 35/-

23 Pawn Broker License Fresh - 45 days Renewal - 30 days 35/-

24 School Registration 1 Week 35/-

25 Birth Certificate - GHMC 15 Mins. (Category-A) 25/- per transaction + statutory charges

5/- per additional copy

26 Death Certificate - GHMC 15 Mins. (Category-A) 25/- per transaction + statutory charges

5/- per additional copy

27 Birth Certificate Corrections - GHMC 6 Working Days 60/- + 25/- per copy of certificate

28 Death Certificate Corrections - GHMC 6 Working Days 60/- + 25/- per copy of certificate

10/- + 25/- per copy of certificate

(after one year)

29 Child Name Inclusion - GHMC 6 Working Days 25/- per copy of certificate

(within one year)

30 Non Availability Certificate Birth - GHMC 3 Working Days 25/- per copy of certificate

NOTE :

1. Postal charges extra.

2. *Subject to availability of online digital records, otherwise the request will be processed within 7 days.

3. Printing of additional pages at ` 2/- per page.

1100 www.meeseva.gov.in