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Annexure-lFQRM OF CASTE CERTIFICATE T'OR SC/ST

This is to certify that Shri*/Shrimati/Kumari Son/Daughter ofVillage/Town /District/Divisionx

of the State,{Jnion Territory belongs to the

Caste*/Tribe which is recognised as a Scheduled Caste/Tribe under

*The Constitution Scheduled Castes Order, 1950.+'l'he Constitution Scheduled Tribes Order, 1950.*The Constitution (Scheduled Castcs) (Union Tenitories) (Pat C States) Order, 1951;+ The Constitution (Schcdulcd 1'ribcs) (Union Tenitories) (Part C States) Order. 1 95 1 ;

fAs amended by the Scheduled Castes and Scheduled Tribes List (Modification Order, 1956, the Bombay Reorganisation Act, 1960, the Punjab

Reorganisation Act, 1966, the State of Himachal Pradesh Act, 1970, the North Eastcm Areas (Reorganisation) Act, 1971 and the Scheduled Castes

and Schedulcd Tribes Ordcrs (Amcndmcnt) Act, 1976.1*The Constitution (Jammu and Kashmir)* Schcduled Castes Orders- 1956.*'I'he Constitution (Andaman and Nicobar lslands)+ Schcduied Tribes Order, 1959, as amcndcd by thc Schcdulcd Castcs and Schedulcd Tribes

Orders (Anendment) Act, 1976*The Constitution (Dadra and Nagar llaveli;+ Schc-dulcd Castcs Ordcr, 1962.*The Constitution (Dadra and Nagar Haveli)* Scheduled Tribes Order, 1 962.*Thc Constitution (Pondichery) Scheduled Castes Order, 1964.*The Constitution (Uttar Pradesh) Scheduled 'l'ribes Order, 1967.+The Constitution (Goa, Daman and Dir.r) Scheduled Castes Order, 1968.*The Constitution (Coa, Daman and Diu) Scheduled'lribes Order, I968.*Thc Constitution (Nagaland) Scheduled 'l'ribes Order, I 970.* l'he Constitution (Sikkim) Scheduled Castes Ordcr, 1978*The Constitution (Sikkim) Scheduled 'Iribes Order, 1978*The Constitution (Jammu & Kashrlir) Scheduled i'ribes Order, 1989.*'l'he Constitution (SC) Orders (Amendment) Act, 1990.*'l he Constitution (S1') Orders (Amendment) Ordinance Act, I 991 .

+Thc Constitution (ST) Orders (Anendment) Ordurance Act, 1 996.+The Constilution (Scheduled Castes) Orders (Amendment) Act, 2002,*'fhe Constitution (Scheduled Castes) Orders (Second Amendment) Aot, 2002.+The Schcduled Castes and Scheduled Tribes Orders (Amendment) Act,2002.

2. Applicable in the case of Scheduled Castes/Scheduled Tribes persons who have migrated from one

StateAJnion Territory Adrnini stration.

This certificate is issued on the basis of the Scheduled Castes/Scheduled Tribes Certificate issued to

Shri/Shrimati* father/mother* of Shri/ShrimatiA(umariof Village/Town* _ in /District/Division*

StateAJnion Territory* who belongs to theof the

Caste*/Tribe which is recognised as a Scheduled Caste/Scheduled 'Iribe in the

StationAJnion Territory* issued by the dated

3. Shri/Shrimati/Kumari* and lor* his/her* family ordinarily reside(s) in Village/Town*District/Division* of the StateAJnion Territoryx of

Place

Date

Signature

Designation(with seal of Office)

StateAJnion Territory*Pleasc dclcte the words, which are not applicablc.

@ Please quote spccific Presidcntial Ordcr(% Delete the Paragraph, which is not applicable.

Notc: (a) The term'ordinarily reside'(s) uscd hcrc will have the same meaning as in Section 20 ofthe Representation ofPeoplcAct, 1950

The Caste Certificate must be issued by thc Compctenl Authorities in the above prescribed fomrat.'lhe Conpetent Authorities are enumerated here

under :

Magistratc/Sub Divisional Magistrate/ [aluka Magistratc/Exccutivc Magistratc/Dxtra AssistaDt C]ommrssioncr.

2. Chief Presideucy M agistratc/Additional C'hic1'Prcs idcrlcy Magistrate/l'res ide ncy \,1 agistratc.

3. Rcvcnuc Offlccr rot bclow the rank of'l ehsildar; and

4. Sub-Divisional Oillccr ofthc arca whcre tllc candidate.rnd/or his l'amily norrnally rcsides.

Ref no:- (O.M.NO.36012/6/88-Estt. (SC'f) dated 24.4.1990 and OM No.36012/22193-Estt(Res) dated 15.1 I .1993 & OM No. 3601 l/3/2009-Estt(Rcs) dated 02.09.2009).

ffi Annexure*II

FORMAT OF'CERTIF'ICATE TO BE PRODUCED BY OTHER BACKWARD CLASSESAPPLYING F'OR APPOINTMENT TO POST UNDER THE GOVERNMENT OF'INDTA.

This is to certi$ that Shri/Smt/Kum*

Son/Daughter* ofShri _District - State belongs to __ comurunity

(indicate the Sub Caste)which is recognized as backward class under

1. Resolution No . 12011168193-8Cc@dtd 101, Septernbe r 1993, published in the Gazette of lndia- Extraordinary Part-I, Section 1 .

No. 1 86 dated I 3tn September 1993.2. ResolutionNo 12011r19194-BCCdatedlgtr,Octoberlgg4,publishedintheGazetteoflndia-ExtraordinaryPart-l,SectionI.No.

.l 63, dated 20*October 1994.

3. Resolution No. -l201 117195-BCC dtd 24tr May 1995, Published in the Gazette of India-Extraordinary Part-I, Section I. No. 88

dated 25,r, May I 995.4. Resolution No . 12011144196-8CC dtd 6tr Deceurber 1996, published in the Gaz-ette of India-Extraordinary Part-I, Section I. No.

210, dated lltr,December 1996.5 ' Resolution No. -l201

1/68/93-BCC, Published in Gazette of India - Extra Ordinary - No. 129, dated the 8,r, July 1997.6. ResolutionNo. l20llll2l96-BCC, Published inGazetteoflndia-ExtraOrdinary-No. l64datedthe 1.tSept. 1997.7 . Resolution No. 1201 1199194-BCC, Published in Gazette of India - Extra Ordinary - No. 236 dated the I

.lrr, Dec. I997.

8. Resolution No. 1201 I113197 -BCC, Published in Gazette of India - Extra Ordinary - No. 239 dated the 3.a Dec. 1997.9. Resolution No. 1201 1112196-BCC, Published in Gazette of India - Extra Ordinary - No. 166 dated the 3,a August I 998.10. ResolutionNo. l20ll/68/93-BCC,Published inGazetteof India-ExtraOrdinary-No. l7l datedthe6tr,August 1998.11. ResolutionNo. 12011/68/98-8CC,PublishedinGazetteof India-ExtraOrdinary ,No.24l datedthe 27r,Oct. 1999.12. ResolutionNo. 12011/88/98-BCC,PublishedinGazetteoflndia-ExtraOrdinary-No.270datedthe6l,Dec. 1999.13. ResolutionNo. 12011136199-BCC,PublishedinGazetteoflndia-ExtraOrdinary,No.Tldatedthe4tr,April 2000.

District of the_State. This is also to certify that he/she does not

belong to the persons / sections (Creamy Layer) mentioned in Colurnn 3 (of the Schedule to the Government of India, Departrnent ofPersontrel and Training O.M. No. 360l2l22l93lEstt. (SCT) dated 08.09.1993) and rrrodified vide Governmelt of India, Department

of Personnel and rraining o.M. No. 360331312004/Estt.(RES). dared 09.03.2004.

of Village /Town -_ __

Place:Date:

District Magistrate/Dy. Commissioner etc(with seal of office)

a. 'fhe term ordinarily useil hrre wiil havr the ger:e meanine as Ser:tion 20 ol"the represe*t.aiiot: of,the poople Acl.. i9"50.b Whert the certificates are issued by ilazetted Oldcers of the l..lnion {iover*me*t or Sital.e fioverrnments. thov

should he in the same fi;rrn hut courlersig,ned by tlle f.)istl'ict i"zlagistri:te ur Xly. {.lomriissi*ner (Ce:tificat*:sissried ir'': Ga;:et{ecl o{Ticels and all*sted by L}is:rict h,{agistlale i,}eput;r (]onimiss:icner are,jilt sul}lcientt.

e. 'I'he OBC c*r-tificaie ficrn rhe authorilies only rvill b* l.toceptedI . Ilistrict Magist raie, Arld itionrl Distrie I \'ir*gislrirt* '{jr:llocir:i.,l)epilty { lofi11e 1ssi1;y1gr, Additional l}*puty

Con.u:rissioner" Deprity {Jullcctor I' {.llass Stipe*diary Magisirare Uxtra-Assislanr Co*rnissione:"{notbelow the rank of'1" {-.lass stipendiar-y 1\4agistrate), t$ubdivisiofial Magi.\trctc 'l'aluka

Magi strate/llxec Lttive N,{agistrate.'2. L'hie1'Presidency &4agistrater'Additional {--.hiq:f Presii}*ncy X..iagistrate'f,resid*ncy Magistrate.3. Reve**e Officer nor below ihe rank oi'f'ahsiidar. and4. Sub-llivisrcnal r:;l cr:r'of the al'*a where 1he car:didete *r.:d'or {ris l'arnill nr:nnal}',, r"esides.

Annexure-lll

Government of ..............(Name & Address of the authority issuing the certificate)

INCOME & ASSETS CERTIFIGATE TO.BE FRoDUcED tsY EcoNoMIcALLY wEAKERSEGTIONS

Certificate No._ Date:

VALID FOR THE YEAR

Thib is to certify that Shri/Smt./Kumari son/daughter/wife ofpermanent resident Village/Street

Post Office District _ in the State/Union TerritoryPin Code photograph is attested below belongs to

Economically Weaker Sections, since the gross annual income* of his/her 'family"l* is below Rs. BIakh (Rupees Eight Lakh only) for the financial year His/her family does not own orpossess any of the following assets*** :

l. 5 acres of agricultural tand and above;ll. Residentialflat of 1000 sq. ft. and above;

lll Residential plot of 100 sq. yards and above in notified municipalities;lV' Residential plot of 200 sq. yards and above in areas other than the notified municipalities.

2. Shri/Smt./Kumari belongs to the caste which is notrecognizedasaSchedutffiotheiBackwardCIasses(CentralList)

lncome

Signature with seal of Office--_--_Name

Designation

etc.

*Note 2:The lerm ]ISPilV' for this purpose include the person, who seeks benefit of reservation, his/her parants and siblings below the ageof l 8 years as also his/her spouse and children below the age of .lB years

***Note 3: The properly held by a "Family" in different locations or different places/cities have been clubbed while applying the land orproperty holding test to determine BA,S status.

attested. photographthe'applicant

sizeof

covered all sources i.e. salary,

SCIIEDUI,E-If (See Rule 0(Medical Fitncss Certificate for Standard of Physical Fitness for Act Apprentice T'raining.

Name of the Candidate : .. .....

Fathcr Name : .......

Category : .......

Date of Birth/Agc : .

Trade & Nam of Workshopfunit : .....

Permanentidentificationmarks 1...2.....

Annexure- IV

Photo to be

attested by theCivil Surgeonwho is giving thecertificafe withSign.ature and

Seal

SN Standard of Physical Fitness Observation ofMedical Officer

1 A candidate should be free evidence ofany contagious or infectious disease. Heshould not be suffering from any disease which is likely to be aggravated byservice or is likely to render him unfit for service or endanger the health of thepublic. He should also be free from evidence of tubercuiosis in any form, activeor healed.

2 Heieht .Weisht and ChestCandidates should satisfy the foilowing minimum standards, namely :- Height :

137 centimeters ; Weight : 25.4 Kilogram ; Chest expansion should not be lessthan 3.8 centimeters irrcspective of size of Chest : Provide that whcre acandidate does not satisfz the said minimum standards but is ccrtified in writingby a Medical Othccr not below the rank of an Assistant Surgeon (Gazetted) tobc physically fit for bcing engaged as an apprentice in a particular trade underthe Apprentices Act, 1 961 , he may be engaged as an apprentice in that trade.

3 EYES ThereShould be no evidence of any morbid condition of either cye of the lids of eithereye which may be liable to risk of aggracation of recurrence. Standard of Vision(A) Visual acuity : *Candidates having vision in one eye sha1l eligible toundergo apprenticeship training except in the following seventeen trades namcly:- (1) Electrician Aircraft (2) Watch and Clock Mechanic (3) Driver cum fitter(4) Survcyor (5) Process Cameraman (6) Sirdar (7) Rigger(Engg. & Chem.Industry) (8) Shortfirer,tslastcr(Mines) (9) Matc (Mines) (10) Mcch. Radio &Radar Aircraft (1 1) Ceramic Modular (12) Ceramic Caster (13) Ccramic KilnOperator (14) Cerarnic Press Opcrator (15) Ceramic Modeller (16) CcramicDecorator ( 1 7) Optical workcr.*Substitute vide GSR 221 dated 21st April 1993.(B) Colour vision : Not required.

4 EARSHearing must bc good in both ears and thcrc should bc no sign of suppurativedisease. No hearing aid shall bc permittcd.

5 SKINThere should be no evidence ofacutc or chronic skin disease or chroniculceration.

Stb4A 4e ?lirkd aa Scdqle P"*. nt 8or/ S,tzo.

t

6. SPEECHSe"ctr stroutd preferably be without impediment

7ALIMENTARY SYSTEML. Candidate should have sufficient number of natural teeth (in healthystate) for mastication.2. Spleen should not be palpably enlarged and there should be noevidence oftenderness in the splenic area.3. Liver should not be palpable or tender.4. There should be no oral sepsis.5. There should be no sugar in the urine.6. Candidates should not be suffering from haemorrhoids, fissure's in and testisanal hernia or bubonocble or ischio-rectai abscess or hydrocele.

8 CARDIO VASCULAR SYSTEM1. Bloodpressure shouid not exceed 85 diastolic and 140 systolic.2. Candidates with low blood pressure (i.e. systolic below 100) should berejected.3. There should be no sign ofany cardiovascular disease

9 RESPIRATORY SYSTEMCandidates should be free flom all diseases of respiratory system. Thereshould be no deformity of chest which may cause impediment to breathing.

10 GENITO URINARY SYSTEMThere should be no evidence ofgenitor urinary disease or anyabnormality.

11

t2 NERVOUS SYSTEMThere should be no evidence ofany diseases ofnervous system or ofanymental diseasc.

13 GLADNULAR SYSTEMTherc should be no evidence oftubcrculosis or other disease ofthe glandularsystem including the cndocrine glands.

t4 X'RAY OF'LI]NGS

15 URINE SUGAR

t6 BLOOD GROUP

Above medical fitness certificate should be signed by Government authorized Doctor (Gaz.), not below rankofAsst. Surgeon of Central State Hospital.

Signature of Medical OfficerName of Medical Officer

Registration No.

DesignationName of Central/State Gove. Hospital

Seal of Medical Officer signing the certificate

SlozH de ?zi*a oa Stagle Po*. ol&ail SdEo.

SKELETAL SYSTEM1. Thc function of all limbs should be within normal lirnits.2. There shor.rld bc no evidence of scrious deformity of thc spinal columnor of the extremitics.

Arrterur?€. - IrFORM-PwD (il)

Form-ll

Disa bility Certificate(ln cases of amputation or complete permanent paralysis of limbs and in cases of blindness)

(See rule 4)

(NAME AND ADDRESS OF THE MEDTCAL AUTHO Rrry tssutNc THE CERTIF|CATE)5,tze

AttestedPhotograph(Shor,ving

only)with

Certificate NoDate

This is to certify that I have carefully examinedShri/Smt./Kum.

son/wife/daughter of ShrDate

of Birth (DD / MM / yy) _Registration No.

Ward/Village/ St

District_Statewhose photograph is a

(A) he/she is a case of:

locomotor disa

blindness

male

a

a

(Please tick as applicab(B) the diagnosis in his/h(A) He/ She has

words) permanent physical

body) as per guidelines (to be

percent (in

(part of

2. The applicant has submitted the of of residence:-of Document ate of lssue Details of authority issuing certificate

(Signature and Seal of Authorised Signatory ofnotified MedicalAuthority)

jNature

Impression of tlreperson In whosefavour disablf itycsr"tificate is

lt*,,1rylr,i:t

FORM-PwD (lll)

Form-lll

Disa bility Certificate(ln case of multiple disabilities)

(NAME AND ADDRESS OF THE MEDTCAL AUTHOR|TY ISSU|NG THE CERTTFICATE)

(See rule 4)

RecentAttestedPltotograph{Showing faceonly) of tlre persrrnr,vith clisabiIEty

stze

Certificate No. Date:

This is to certify that we have carefully examined

Shri/Smt./Kum.

/son/wife/daugh ter of Shri

Date of Birth (DD / MM IYY)_ Age years, male/femaRegistration No. anent resident of House No.

Wa rdlVillage/Stre

Post Office

s.

No.

Part

physica I

ed) for the

table below

cal impairment/mental

ability (in %)Disability

Locomotor

bility

Low vision

Hearing

1.

i;-r-l

iq

l

t.**"i-:5:

ir-i5t

nesndB S Both

_t..^

mpairment

Mental

reta rdation

Mental-illness

(B) ln the light of the above, his /her over all permanent physical impairment as perguidelines(to be specified), is as follows:-

ln figures:- percent

In words:-

2. This condition is progressive/ non-progressive/ likely to improve/ not likely to improve

lo

whose photograph is

(A) He/she is a Case ofi m pa i rm ent/d isa bi I itydisabilities ticked

3. Reassessment of disability is:

(i) not necessary,

Or

(ii)isrecommended/afteryearS-months,andthereforethis

@ - e.g. Left/Right/both arms/legs

# - e.g. Single eye/both eyes

f - e.g. Left/Right/both ears

4. The applicant has submitted the following document as proof of residence:-.

5. Signature and seal ofthe Medical Authority

Name and seal of Mem ame a

Details of authority issuing

certificateDate of lssue

person

and seal ofthe

.!.T

t:. ::l :::,

Nature of Document

.l)

"impression of tfreperson In w[roselavour disablIitycertiftcate is

FoRM-PwD (lV)

* ,orm-lv

Disa bility Certificate(ln cases other than those mentioned in Forms ll and lll)

(NAME AND ADDRESS oF rHE'ril"T:i:li'o*'rr rssurNc rHE CERT!FTCATE)

5[Ze

AttestedPhotograph(Si'rowing faceonty) of the per-sonwith clisabitlty

Certificate No. Date:

This is to certify that I have carefully examined

Shri/Smt./Kum. _son/ wife/daughter of Sh

Date of Birth (DD / MM IYY) _ Age_years, male/fema

District tate whose photograph is affixed above,

and am satisfied that he/she

His/her extent of percentage

guidelines (to be specified) ar

d isabilityphysical

nd is sh own against the releva

s.

No.Disability Diagnos

'ilr.1

essBlindn

Locomotor

d isa b ility

Low vision

Hearing

impairment

Mental

a rdation

;4ffi#

j

lqi!

l

lsI

i6i Mental-illness .x

(Please strike out the disabilities which are not applicable.)

2. The above condition is progressive/ non-progressive/ likely to improve/ not likely toimprove.

3. Reassessment of disability is :

(i) not necessary,

Or

cal impairment/mental

disability (in %)

Per

Registration of House N

luated as per

the table below:-

Ward/Village/

;,ai.*1

@ - e.g. Left/Right/both arms/egs# - e.g. Single eye/both eyesf - e.g. Left/Right/both ears

The applicant has submitted the followi

nths, and therefore this certificate

ng document as proof of resid ce

Nature of Document Date of lssue

(Authorised Signatory of notified Medica I Authority)(Name and Seal)

Countersigned

iCountersignature and seal of theCMO/Medical Superintendent/Head ofGovernment Hospital, in case thecertificate is issued by a medicalauthority who is not aservant (with seal))

Note: ln case thisservant, it shall be

Note: The principal

S.O. 908(E), dated the

a government

r of the Districtnotification number

Details of authority issuing

certificate

.,:,.

.:i r ri :rrlmpresslon ofperson In

certlftratefavour

Annexure-VI

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