8/12/2019 Caste Applicationform

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APPLICATION FORM

SCHEDULED CASTE CLASS / SCHEDULE TRIBE CLASS

BACKWARD CLASS FOR PROFORMA

To,

______________ Mandal,

Hyderabad, A.P.

Sir,

1. Name of the Applicant(In Block Letters & Full) : ______________________________________________

2. Fathers Name : ______________________________________________

3. Sex : ______________________________________________

4. Native Place

(Origin District) : ______________________________________________

5. Present Address H.No. : ______________________________________________

6. Caste Claimed

S.C./ S.T. /B.C. /O.C. : ______________________________________________

7. List of Documents enclosedT.C. from the recognizedSchool or College of Caste : ______________________________________________Certificate earlier if anyTo the family member

8. Origin of Present AgeAffidavit duly enclosed : ______________________________________________

9. Copy of the Ration Card : ______________________________________________

10. Two different GazettedOfficers Certificate ofState Govt. : ______________________________________________

DECLARATION

I declare that the information furnished by me in this application is true and correct and that it is

found to be untrue and incorrect, I will be liable for prosecution for furnishing false information under

Section 199 and 200 of I.P.C.

SIGNATURE OF THE APPLICANT

Date: / /20 ( )

Place: Hyderabad, A.P

Certificates enclosed: ( )

1) Two different State Govt. Gazetted Officer Certificate.2) Affidavit with Notary on Rs. 10/- Bond Paper.3) T.C, Bonafide & S.S.C Memo Xerox with Attested by the State Govt. Gazetted Officer.4) Ration card with Attested by the State Govt. Gazetted Officer.5) Photo Identity Card issued by the Election Commission or Electorate rolls from Municipality.6) Caste Certificate issued to any of the family members Xerox attested by the State Govt. Gazetted Officer.7) Certificate from the Registered Caste Sangham or any family member Caste Certificate Xerox attested by the

Gazetted Officer.

Affix 2 Rupees

Court Fee Stamp

8/12/2019 Caste Applicationform

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Form of Caste Certificate

This is to certify that claim of Sri/Smt/Kum.______________________________________________________

S/o.D/o.W/o ________________________________Village/town H No._______________________________________

___________________________________________Taluka ______________________________________in the district

_________________________________of the state __________________________________________________has

been verified as per the procedure laid down and he/she belongs to the _________________________________________

be/Backward classes under ___________________________________________________________________

The constitution (Schedule Castes) Order, 1950. The constitution (Schedule Tribe) Order, 1950.

G. O. Ms. No. 1793 Education date 23-9-70 as amended from time to time.

(As amended by the Scheduled Castes and Scheduled Tribe Lists (Modification) order, 1956 the SC & ST amended)

2. Sri/Smt/Kum. _________________________________________and his/her family ordinarily resides in village/town

H.No. _____________________________________________________________________________of Dist/Divn.

_______________________________of the state of ______________________________________ of place

_______________________________________state______________________________________________ .

Signature of the State Gazetted OfficerDate:

Designation:

Official Seal:

NAME:

Form of Caste Certificate

This is to certify that claim of Sri/Smt/Kum.______________________________________________________

S/o.D/o.W/o ________________________________Village/town H No._______________________________________

___________________________________________Taluka ______________________________________in the district

_________________________________of the state __________________________________________________has

been verified as per the procedure laid down and he/she belongs to the _________________________________________

be/Backward classes under ___________________________________________________________________

The constitution (Schedule Castes) Order, 1950. The constitution (Schedule Tribe) Order, 1950.

G. O. Ms. No. 1793 Education date 23-9-70 as amended from time to time.(As amended by the Scheduled Castes and Scheduled Tribe Lists (Modification) order, 1956 the SC & ST amended)

2. Sri/Smt/Kum. _________________________________________and his/her family ordinarily resides in village/townH.No. _____________________________________________________________________________of Dist/Divn.

_______________________________of the state of ______________________________________ of place

_______________________________________state______________________________________________ .

Signature of the State Gazetted Officer

Date:

Designation:

Official Seal:

NAME: