ANNEXURE IV

APPLICATION FORM FOR A CERTIFICATE FOR ELIGIBILITY FOR

RESERVATION OF JOBS FOR OTHER BACKWARD CLASSES IN CIVIL
POSTS AND SERVICES UNDER GOVERNMENT OF INDIA
_____________________________
_____________________________
_____________________________
Sir,
I request that a certificate in respect of reservation for other Backward classes in Civil Posts and Services under Government
of India be granted to me.

I give the necessary particulars

1. Full Name of the applicant (in Block letters) -

2. Date of birth -
3. Complete residential address (a) Present -

(b) Permanent -

4. Religion -
5. Caste -
6. Sub Caste -
7. Occupational group -
8. Serial No. of the caste in the Central list of OBCs -
9. Name of Father -
10. Name of mother -
11. Name of Husband -
12. Status of Parent(s) Husband Father Mother Husband
a) Constitutional Post
(1) Designation
b) Government service
(i) Service (Central/State) Father Mother Husband
(ii) Designation
(iii) Scale of pay including
classification if any
(iv) Date of appointment to the post
(v) Age at the time of promotion to
Class I Post (if applicable)
II. Employment in International organization e.g. U.N., UNICEF, WHO Father Mother Husband
(i) Name of organization
(ii) Designation
(iii) Period of service (indicate date from…………….to…………)
III. Death/Permanent incapacitation (Omit if not applicable)
i) Date of death/permanent incapacitation putting an officer out of service
ii) Details of permanent incapacitation -
C) Employment of Public Sector undertaking etc -
i) Name of Organisation -
ii) Designation -
iii) Date of appointment to the post -

D) Armed forces including paramilitary forces (This will not include persons
holding civil posts)
i) Designation -
ii) Scale of pay -

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E) Professional class -
Other than those covered in item Nos. B & C and those engaged in \
trade, Business and industry

(i) Occupation/profession -
F) Property owners
G) Agricultural Land Holding: Owned by mother father and minor children
i) Location -

ii) Size of holding -

iii) (a) Irrigated (type of irrigated land)

(i)
(ii)
(iii)
(b) Unirrigated -.
iv) Percentage of Irrigated land holding to Statutory ceiling limit under State
Land Ceiling Laws.
If land holding is
v) Both the irrigated/unirrigated total irrigated land holdings on the basis of
conversion formula in State Land Ceiling laws. (To be
certified by District Revenue Officer not lower than the rank of
Tahsildar)
vi) Percentage of total irrigated land holding to statutory ceiling limit as per
(iv)
H) If Plantations.
(i) Crops/Fruits -
(ii) Location -
(iii) Area of plantation -
I) III. Vacant Land/or buildings in urban areas or urban agglomeration -
i) Location of property -
ii) Details of property -
iii) Use to which it is put -
J) Income/Wealth
i) Annual family income from all sources (excluding salaries & Income
from Agricultural lands) -
ii) Whether tax payer (Yes/No) (If yes a copy of the last three years return
be furnished) -
iii) Whether covered in Wealth Tax Act (Yes/No) (If so furnish details) -
I) I certify that the above said particulars are true to the best of my knowledge and belief and that I do not belong to the Creamy
Layer of OBCs and am eligible to be considered for posts reserved for OBCs. In the event of any information being found false or
incorrect or ineligibility being detected before or after this 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 the law and/or rules.
Yours faithfully,
Place :
Date :

Signature of candidate.

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 CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES
(OBCs) FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF
INDIA

This is to certify that Shri/Smt/Kumari …………………….

………………….. ...............................................................................................................
..........................son/daughter of Shri/Smt……………………………. Of Village….
………………….. District/Division……………………… in
the……………………………………… State ……………………………………..
belongs to the…………………………. Community which is recognized as a backward
class under the Government of India Ministry of Welfare Resolution No. Resolution No.
12011/68/93-BCC(C) dated the 10th September 1993 published in the Gazette of India
Extra ordinary Part I, Section I dated 13th September 1993.

I. Government of India, Ministry of Welfare Resolution No. 12011/9/94-BCC dated

19th October 1994 published in the Gazette of India Extraordinary Part I Section I,
No. 163, dated 20th October 1994.

II. Resolution No. 12011/7/95-BCC, dated the 24th May 1995 published in the
Gazette of India Extra ordinary Part I Section I, No. 88, dated 25th May 1995.

Shri/Smt/Kumari…………………. ……………………..and/or his/her family

ordinarily reside(s) in the………………………District/Division of
the…………………………. state. This is also to certify that he/she does not belong to
the persons/sections (Creamy Layer) mentioned in column 3 of the schedule to the
Government of India, Department of Personnel & Training O.M. No. 36012/22/93-Estt.
(SCTI) dated 8..9..1993.

Dated:

District Magistrate/Tahsildar, Deputy Commissioner etc.

Seal

Note: (I) The term 'ordinarily' used here will have the same meaning as section 20 of the
Representation of People Act, 1950

Note: (II) The OBC certificate from the following authorities only will be accepted

(i) District Magistrate/Additional Magistrate/Collector/Deputy Commissioner/

Additional Deputy Commissioner/Deputy Collector/I Class Stipendiary
Magistrate/Sub Divisional Magistrate/Taluk Magistrate/Executive
Magistrate/Extra Assistant Commissioner (Not below the rank of Ist class
Stipendiary Magistrate)

(ii) Chief Presidency Magistrate/Additional Chief Presidency

Magistrate/Presidency Magistrate

(iii) Revenue Officer not below the rank of Tahsildar, and

(iv) Sub Divisional Officer of the area where the candidate and/or his family
resides.

0098
 CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES
(OBCs) FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF
INDIA

This is to certify that Shri/Smt/Kumari …………………….

………………….. ................................................................................................................
.........................son/daughter of Shri/Smt……………………………. Of Village….
………………….. District/Division……………………… in
the……………………………………… State ……………………………………..
belongs to the…………………………. Community which is recognized as a backward
class under the Government of India Ministry of Welfare Resolution No. Resolution No.
12011/68/93-BCC(C) dated the 10th September 1993 published in the Gazette of India
Extra ordinary Part I, Section I dated 13th September 1993.

III. Government of India, Ministry of Welfare Resolution No. 12011/9/94-BCC dated

19th October 1994 published in the Gazette of India Extraordinary Part I Section I,
No. 163, dated 20th October 1994.

IV. Resolution No. 12011/7/95-BCC, dated the 24th May 1995 published in the
Gazette of India Extra ordinary Part I Section I, No. 88, dated 25th May 1995.

Shri/Smt/Kumari…………………. ……………………..and/or his/her family

ordinarily reside(s) in the………………………District/Division of
the…………………………. state. This is also to certify that he/she does not belong to
the persons/sections (Creamy Layer) mentioned in column 3 of the schedule to the
Government of India, Department of Personnel & Training O.M. No. 36012/22/93-Estt.
(SCTI) dated 8..9..1993.

Dated:

District Magistrate/Tahsildar, Deputy Commissioner etc.

Seal

Note: (I) The term 'ordinarily' used here will have the same meaning as section 20 of the
Representation of People Act, 1950

Note: (II) The OBC certificate from the following authorities only will be accepted

(i) District Magistrate/Additional Magistrate/Collector/Deputy Commissioner/

Additional Deputy Commissioner/Deputy Collector/I Class Stipendiary
Magistrate/Sub Divisional Magistrate/Taluk Magistrate/Executive
Magistrate/Extra Assistant Commissioner (Not below the rank of Ist class
Stipendiary Magistrate)

(ii) Chief Presidency Magistrate/Additional Chief Presidency

Magistrate/Presidency Magistrate

(iii) Revenue Officer not below the rank of Tahsildar, and

(iv) Sub Divisional Officer of the area where the candidate and/or his family
resides.

0098
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¯n-te¡v t\m¬ {Ioan-se-bÀ kÀ«n-^n-¡-än-\pÅ
dnt¸mÀ«v
1. At]-£-Isâ t]cpw hnem-khpw .
(C-t¸m-gs¯ hnem-k-¯n P\n- .
¨p-h-fÀ¶-X-Ãm-sb-¦n ap³
hnem-khpw ImWn-¡-Ww.)

2. kÀ«n-^n-¡-änsâ Bhiyw .
(F-hnsS kaÀ¸n-¡p-hm³ BWv .
F¶v hyà-am-¡-Ww)

3. At]-£-Isâ P\\ XobXn .

.
4. aXw þ PmXn þ D]-PmXn .
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5. At]-£-Isâ IpSpw-_s¯ kw_-Ôn-¡p¶ hnh-c-§Ä

(A-t]-£-I³ hnhm-ln-X-\m-sW-¦nepw AsÃ-¦nepw amXm-]n-
Xm-¡-fpsS t]cpw tPmenbpw hcp-am-\hpw hyà-am-¡-Ww.
kÀ¡mÀ Poh-\-¡m-cpsS ASn-Øm\ i¼-fw Un.-F. bpw IW-¡n-se-
Sp-¡-Ww.

{Ia \ t]cv hbÊv At]-£- tPmen {]Xn- aäp

¼À I-\p- hÀj hnh-c-
am- hcp- §Ä
bpÅ am\w
_Ôw

6. At]-£-I\pw IpSpw-_-¯n-\p-apÅ hkvXp-¡-fpsS hnh-c-Ww.

X-t¸À \¼À .
.
kÀtÆ \¼À .
.
hnkvXo˨w .
.
C\w . ]pc-bnSw/\new
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BsI hcp-am\w . .......................................
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0098
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7. sI«n-S-§Ä/BUn-täm-dnbw .
apX-em-bh hmS-Ibv¡p sImSp- .
¯n-«p-s-¦n {]Xn-amk hcp-
am\w

8. At]-£-Isâ IpSpw-_-¯nÂs¸« Bsc-¦nepw Xmsg ]d-bp¶ hn`m-K-

¯nÂs¸-«-h-cptm? Ds-¦n {]tXyI hnh-cWw Xc-Ww.

1. `c-W-L-S\m DtZym-K-ØÀ .
.
2. t\cn-«pÅ \nb-a-\-¯n-eqsS .
¢mÊvþ1 DtZymKw In«n-b-hÀ .

3. 40 hb-Ên\v ap¼v t{KUv-þ1, .

t{KUvþ2 (F), t{KUv-þ2 (_n) .
F¶o DtZymKw In«n-b-hÀ

t{KUv-þ1 9000 cq]bv¡v ta ASn-Øm\ i¼fw DÅ-hÀ (h-Ip-

¸p-X-e-h-·mÀ, a{´n-am-cpsS ss{]häv sk{I-«-dn-
amÀ, sF.-F.-F-kv. DtZym-K-ØÀ)

t{KUv-þ2 (F) 7500 cq] apXÂ 9000 cq] hsc ASn-Øm\ i¼-
f-ap-Å-hÀ

t{KUv-þ2 (_n) 4800 cq] apXÂ 7500 cq] hsc ASn-Øm\ i¼-
f-ap-Å-hÀ
4. kmbp[ tk\-bn "tIWÂ' apX .
apI-fn-ep-Å-hÀ .

5. h¡oÂ, tUmIvSÀ, NmÀt«Uv .

A¡u-âv, C³Iw SmIvkv I¬kÄ«âv, .
F©n-\o-bÀ, kn\na, hyh-km-b-
hp-ambn _Ô-s¸-«-hÀ

6. tXm«-§Ä DÅ-hÀ (A©v slIvS- .

dn IqSp-XÂ) .

7. 15 e£w cq]-bn IqSp-X sjb- .

dmbn \nt£-]n¨v _nkn-\Êv \S- .
¯p-¶-hÀ

8. 20 e£w cq]-bn IqSp-X .

tStWm-h-dpÅ {SÌn-tâtbm .
skmssk-än-bp-tStbm
HutZym-KnI `mc-hm-lnXzw
DÅ-hÀ

9. s]mXp-ta-Je Øm]-\-§Ä, _m¦p- .

IÄ, C³jz-d³kv I¼-\n-IÄ, bqWn- .
th-gvknän F¶n-hn-S-§-fnÂ
3þÂ kqNn-¸n-¨n-cn-¡p¶
t{KUn\p Xpey-ambn tPmen
DÅ-hÀ
10 aäp-Iq-Sp-X hnh-c-§Ä .
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t]cv :

Øew :

XobXn: hntÃPv Hm^o-

kÀ

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¯n-te¡v t\m¬ {Ioan-se-bÀ kÀ«n-^n-¡-än-\pÅ
dnt¸mÀ«v
1. At]-£-Isâ t]cpw hnem-khpw .
(C-t¸m-gs¯ hnem-k-¯n P\n- .
¨p-h-fÀ¶-X-Ãm-sb-¦n ap³
hnem-khpw ImWn-¡-Ww.)

2. kÀ«n-^n-¡-änsâ Bhiyw .
(F-hnsS kaÀ¸n-¡p-hm³ BWv .
F¶v hyà-am-¡-Ww)

3. At]-£-Isâ P\\ XobXn .

.
4. aXw þ PmXn þ D]-PmXn .
.

5. At]-£-Isâ IpSpw-_s¯ kw_-Ôn-¡p¶ hnh-c-§Ä

(A-t]-£-I³ hnhm-ln-X-\m-sW-¦nepw AsÃ-¦nepw amXm-]n-
Xm-¡-fpsS t]cpw tPmenbpw hcp-am-\hpw hyà-am-¡-Ww.
kÀ¡mÀ Poh-\-¡m-cpsS ASn-Øm\ i¼-fw Un.-F. bpw IW-¡n-se-
Sp-¡-Ww.

{Ia \ t]cv hbÊv At]-£- tPmen {]Xn- aäp

¼À I-\p- hÀj hnh-c-
am- hcp- §Ä
bpÅ am\w
_Ôw

6. At]-£-I\pw IpSpw-_-¯n-\p-apÅ hkvXp-¡-fpsS hnh-c-Ww.

X-t¸À \¼À .
.
kÀtÆ \¼À .
.
hnkvXo˨w .
.
C\w . ]pc-bnSw/\new
.
BsI hcp-am\w . .......................................
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0098
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7. sI«n-S-§Ä/BUn-täm-dnbw .
apX-em-bh hmS-Ibv¡p sImSp- .
¯n-«p-s-¦n {]Xn-amk hcp-
am\w

8. At]-£-Isâ IpSpw-_-¯nÂs¸« Bsc-¦nepw Xmsg ]d-bp¶ hn`m-K-

¯nÂs¸-«-h-cptm? Ds-¦n {]tXyI hnh-cWw Xc-Ww.

1. `c-W-L-S\m DtZym-K-ØÀ .
.
2. t\cn-«pÅ \nb-a-\-¯n-eqsS .
¢mÊvþ1 DtZymKw In«n-b-hÀ .

3. 40 hb-Ên\v ap¼v t{KUv-þ1, .

t{KUvþ2 (F), t{KUv-þ2 (_n) .
F¶o DtZymKw In«n-b-hÀ

t{KUv-þ1 9000 cq]bv¡v ta ASn-Øm\ i¼fw DÅ-hÀ (h-Ip-

¸p-X-e-h-·mÀ, a{´n-am-cpsS ss{]häv sk{I-«-dn-
amÀ, sF.-F.-F-kv. DtZym-K-ØÀ)

t{KUv-þ2 (F) 7500 cq] apXÂ 9000 cq] hsc ASn-Øm\ i¼-
f-ap-Å-hÀ

t{KUv-þ2 (_n) 4800 cq] apXÂ 7500 cq] hsc ASn-Øm\ i¼-
f-ap-Å-hÀ
4. kmbp[ tk\-bn "tIWÂ' apX .
apI-fn-ep-Å-hÀ .

5. h¡oÂ, tUmIvSÀ, NmÀt«Uv .

A¡u-âv, C³Iw SmIvkv I¬kÄ«âv, .
F©n-\o-bÀ, kn\na, hyh-km-b-
hp-ambn _Ô-s¸-«-hÀ

6. tXm«-§Ä DÅ-hÀ (A©v slIvS- .

dn IqSp-XÂ) .

7. 15 e£w cq]-bn IqSp-X sjb- .

dmbn \nt£-]n¨v _nkn-\Êv \S- .
¯p-¶-hÀ

8. 20 e£w cq]-bn IqSp-X .

tStWm-h-dpÅ {SÌn-tâtbm .
skmssk-än-bp-tStbm
HutZym-KnI `mc-hm-lnXzw
DÅ-hÀ

9. s]mXp-ta-Je Øm]-\-§Ä, _m¦p- .

IÄ, C³jz-d³kv I¼-\n-IÄ, bqWn- .
th-gvknän F¶n-hn-S-§-fnÂ
3þÂ kqNn-¸n-¨n-cn-¡p¶
t{KUn\p Xpey-ambn tPmen
DÅ-hÀ
10 aäp-Iq-Sp-X hnh-c-§Ä .
. .

0098
 H¸v :

t]cv :

Øew :

XobXn: hntÃPv Hm^o-

kÀ

0098