APPLICATION FORM

SCHEDULED CASTE CLASS / SCHEDULE TRIBE CLASS

BACKWARD CLASS FOR PROFORMA
To,
______________ Mandal,
Hyderabad, A.P.

Affix 2 Rupees
Court Fee Stamp

Sir,
1.

Name of the Applicant

(In Block Letters & Full)

______________________________________________

2. Fathers Name

______________________________________________

3. Sex

______________________________________________

______________________________________________

5. Present Address H.No.

______________________________________________

6. Caste Claimed
S.C./ S.T. /B.C. /O.C.

______________________________________________

______________________________________________

8. Origin of Present Age

Affidavit duly enclosed

______________________________________________

9. Copy of the Ration Card

______________________________________________

10. Two different Gazetted

Officers Certificate of
State Govt.

______________________________________________

4. Native Place
(Origin District)

7. List of Documents enclosed

T.C. from the recognized
School or College of Caste
Certificate earlier if any
To the family member

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)
2)
3)
4)
5)
6)
7)

Two different State Govt. Gazetted Officer Certificate.

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

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

_______________________________of

the

state

of

Dist/Divn.

______________________________________

of

place

_______________________________________state______________________________________________ .
Signature of the State Gazetted Officer
Date:
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/town
H.No.

_____________________________________________________________________________of

_______________________________of

the

state

of

Dist/Divn.

______________________________________

_______________________________________state______________________________________________ .
Signature of the State Gazetted Officer
Date:
Designation:
Official Seal:
NAME:

of

place