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    Annexure - III: Formats For Certificates

    Uploaded by

    Tarun Kumar S
    The document provides formats for certificates required for candidates applying under different reserved categories: 1. An OBC undertaking declaration format requiring candidates to declare their caste and that they do not fall under the creamy layer. 2. A format for an OBC certificate to be issued by competent authorities listing the resolutions under which the candidate's caste is recognized as OBC. 3. Formats for SC/ST certificates listing the relevant constitutional orders and requiring details of the candidate's caste and certifying authority. 4. A format for PWD/physically challenged certificates requiring medical details of the candidate's disability to be filled by a medical board.

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    Annexure - III: Formats For Certificates

    Uploaded by

    Tarun Kumar S
    76 views6 pages
    The document provides formats for certificates required for candidates applying under different reserved categories: 1. An OBC undertaking declaration format requiring candidates to declare their caste and that they do not fall under the creamy layer. 2. A format for an OBC certificate to be issued by competent authorities listing the resolutions under which the candidate's caste is recognized as OBC. 3. Formats for SC/ST certificates listing the relevant constitutional orders and requiring details of the candidate's caste and certifying authority. 4. A format for PWD/physically challenged certificates requiring medical details of the candidate's disability to be filled by a medical board.

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    The document provides formats for certificates required for candidates applying under different reserved categories: 1. An OBC undertaking declaration format requiring candidates to declare their caste and that they do not fall under the creamy layer. 2. A format for an OBC certificate to be issued by competent authorities listing the resolutions under which the candidate's caste is recognized as OBC. 3. Formats for SC/ST certificates listing the relevant constitutional orders and requiring details of the candidate's caste and certifying authority. 4. A format for PWD/physically challenged certificates requiring medical details of the candidate's disability to be filled by a medical board.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    76 views6 pages

    Annexure - III: Formats For Certificates

    Uploaded by

    Tarun Kumar S
    The document provides formats for certificates required for candidates applying under different reserved categories: 1. An OBC undertaking declaration format requiring candidates to declare their caste and that they do not fall under the creamy layer. 2. A format for an OBC certificate to be issued by competent authorities listing the resolutions under which the candidate's caste is recognized as OBC. 3. Formats for SC/ST certificates listing the relevant constitutional orders and requiring details of the candidate's caste and certifying authority. 4. A format for PWD/physically challenged certificates requiring medical details of the candidate's disability to be filled by a medical board.

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    Annexure III:

    Formats for Certificates

    OBC Undertaking

    OBC Undertaking
    Declaration / undertaking - for OBC Candidates only

    I, ____________________ son/daughter of Shri ______________ resident of village/town/city ____________ district


    ____________ State hereby declare that I belong to the ___________ community which is recognised as a backward
    class by the Government of India for the purpose of reservation in services as per orders contained in Department of
    Personnel and Training Office Memorandum No.36012/22/93- Estt. (SCT), dated 8/9/1993. It is also declared that I do not
    belong to persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the above referred Office
    Memorandum, dated 8/9/1993, which is modified vide Department of Personnel and Training Office Memorandum
    No.36033/3/2004 Estt.(Res.) dated 9/3/2004.I also declare that the condition of status/annual income for creamy layer of
    my parents/guardian is within prescribed limits as on financial year ending on March 31, 2016.

    Place:
    Date:

    Declaration/undertaking not signed by Candidate will be rejected

    Signature of the Candidate

    OBC Certificate Format

    OBC Certificate Format


    FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT
    TO POSTS / ADMISSION TO CENTRAL EDUCATIONAL INSTITUTES (CEIs), UNDER THE GOVERNMENT OF
    INDIA
    This certificate MUST have been issued on or after 1stApril2016.

    This is to certify that Shri/Smt./Kum. _____________________________ Son/Daughter of Shri/Smt. __________________________________ of


    Village/Town ________________________________ District/Division __________________________ in the _________________________
    State belongs to the ________________________ Community which is recognized as a backward class under:
    (i)

    Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of India Extraordinary Part I Section I No. 186 dated
    13/09/93.
    (ii) Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India Extraordinary Part I Section I No. 163 dated 20/10/94.
    (iii) Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India Extraordinary Part I Section I No. 88 dated 25/05/95.
    (iv) Resolution No. 12011/96/94-BCC dated 9/03/96.
    (v) Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India Extraordinary Part I Section I No. 210 dated 11/12/96.
    (vi) Resolution No. 12011/13/97-BCC dated 03/12/97.
    (vii) Resolution No. 12011/99/94-BCC dated 11/12/97.
    (viii) Resolution No. 12011/68/98-BCC dated 27/10/99.
    (ix) Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India Extraordinary Part I Section I No. 270 dated 06/12/99.
    (x) Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India Extraordinary Part I Section I No. 71 dated
    04/04/2000.
    (xi) Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India Extraordinary Part I Section I No. 210 dated
    21/09/2000.
    (xii) Resolution No. 12016/9/2000-BCC dated 06/09/2001.
    (xiii) Resolution No. 12011/1/2001-BCC dated 19/06/2003.
    (xiv) Resolution No. 12011/4/2002-BCC dated 13/01/2004.
    (xv) Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of India Extraordinary Part I Section I No. 210 dated
    16/01/2006.
    Shri/Smt./Kum. ________________________ and/or his family ordinarily reside(s) in the __________________________ District/Division of
    ________________________ 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.(SCT) dated 08/09/93 which
    is modified vide OM No. 36033/3/2004 Estt.(Res.) dated 09/03/2004.

    Dated:
    District Magistrate/
    Deputy Commissioner, etc.
    Seal
    NOTE:
    (a)
    (b)

    The term Ordinarily used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.
    The authorities competent to issue Caste Certificates are indicated below:
    (i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner / Deputy
    Collector / First Class Stipendiary Magistrate / Sub-Divisional magistrate / Taluka 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 Tehsildar and
    (iv) Sub-Divisional Officer of the area where the candidate and / or his family resides.
    OBC Certificate issued from Maharashtra State must be validated by social welfare Department of Maharashtra Government

    SC/ST Certificate Format

    SC/ST Certificate Format


    FORM OF CERTIFICATE TO BE PRODUCED BY A CANDIDATE BELONGING TO SCHEDULED CASTE OR SCHEDULED TRIBE
    This is to certify that Shri/Smt./Kum._____________________________________________________________ Son/Daughter of Shri ________________
    _______________________________of village/Town_______________________in District/ Division _____________________________ of the State/Union
    Territory _____________________________ belongs to the __________________ caste/Tribe, which is recognized as a Schedule Caste/Scheduled Tribe
    under.
    The Constitution (Scheduled Castes) order, 1950.
    The Constitution (Scheduled Tribes) order, 1950.
    The Constitution (Scheduled Castes)(Union Territory) order, 1951.
    The Constitution (Scheduled Tribes) (Union Territory) order, 1951.
    (As amended by the Scheduled Castes and Scheduled Tribes (Modification) Order 1956, the Bombay Reorganization Act, 1960, the Punjab
    Reorganization Act, 1966, The State of Himachal Pradesh Act, 1970, the North Eastern Areas (Reorganization Act, 1971) and the Scheduled Castes
    and Scheduled Tribes orders (Amendment) Act, 1976.)
    *The constitution (Jammu & Kashmir) Scheduled Caste Order, 1956;
    *The Constitution (Andaman and Nicobar Islands) Scheduled Tribes, 1959, as amended by the Scheduled Castes and Scheduled Tribes orders
    (Amendment) Act. 1976;
    *The Constitution (Dadra and Nagar Haveli) Scheduled Castes Order 1962;
    *The Constitution (Dadra & Nagar Haveli) Scheduled Tribes Order, 1962;
    *The Constitution (Pondichery) Scheduled Castes Order, 1964;
    *The Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967;
    *The Constitution (Goa, Daman &Dieu) Scheduled Castes Order, 1968;
    *The Constitution (Goa, Daman &Dieu) Scheduled Tribes Order, 1968;
    *The Constitution (Nagaland) Scheduled Tribes Order, 1970;
    *The Constitution (Sikkim) Scheduled Castes Order, 1978;
    *The Constitution (Sikkim) Scheduled Tribes Order, 1978;
    *The Constitution (Scheduled Castes) Orders (Amendment) Act, 1990.
    *The Constitution (Scheduled Tribes) Order, (Amendment) Ordinance, 1991.
    *The Constitution (Scheduled Tribes) Order, (Second Amendment) Act, 1991.
    *The Constitution (Scheduled Tribes) Ordinance, 1996
    This certificate is issued on the basis of the Scheduled Castes/Scheduled Tribes Certificate issue to
    Shri ____________________________________________Father of Shri _____________________________________ ______of
    village/town__________________________________ in District/Division _________________________________ of the State/UT _________________
    _____________who belongs to the ___________________ caste/Tribe which is recognized as a SC/ST in the State/Union Territory
    __________________________________ issued by the ____________________________________ (name of the prescribed issuing authority) vide their
    No. ______________________________________________ dated _______________ or Shri ____________ _____________________________ and or
    his/her family ordinarily reside(s) in Village/Town __________________________of ___________________ District/Division of the State/Union Territory
    of ____________________.

    Place______________
    Date_______________

    Signature______________
    Designation ____________
    (With seal of Office)
    NOTE: - The terms ordinarily reside(s) used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.
    SC Certificate issued from Maharashtra State must be validated by Social Welfare Department and ST Caste certificate must be validated by
    Tribal Development Department of Maharashtra Government
    LIST OF AUTHORITIES EMPOWERED TO ISSUE CASTE/TRIBE CERTIFICATE:
    1. District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner /Additional Deputy Commissioner/Dy. Collector/
    Magistrate/Sub Divisional Magistrate/Extra Assistant Commissioner/Taluka Magistrate/Executive Magistrate.
    2. Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.
    3. Revenue Officers not below the rank of Tahsildar.
    4. Sub-Divisional Officers of the area where the candidate and/or his family normally resides.

    1st

    Class Stipendiary

    PWD Certificate Format

    PWD Certificate Format


    Format for Physically Challenged (PH)/Persons with Disabilities (PWD) Certificate
    (To be obtained by the candidate)
    (To be filled by Medical Board notified under PWD Act)
    Affix here recent
    Photograph showing
    the disability duly
    attested by Medical
    Superintendent
    /CMO/Head of
    Hospital (with seal)

    Certificate No:
    Date:

    This is to certify that Mr./Ms______________________________________________________________ son / daughter of


    Mr./Mrs._____________________________________________________

    Age

    ______________male/female,

    Registration

    No._____________________________is a case of ______________________________. He/She is physically disabled/visual


    disabled/speech and hearing disabled/having mental retardation/leprosy cured and has %(______________________per cent)
    permanent

    (physical

    impairment/visual

    impairment/speech

    and

    hearing impairment

    etc.)

    in

    relation

    to

    his/her

    __________________________________________.
    Note:
    This condition is progressive/not progressive/likely to improve/not likely to improve*.
    1. Re-assessment is not recommended/ is recommended after a period of___________ months / years*.
    (*Strike out whichever is not applicable)
    Signature of Dr.

    Signature of Dr.

    Signature of Dr.

    Name of Dr.

    Name of Dr.

    Name of Dr.

    Specialization

    Specialization

    Specialization

    Seal with Degree

    Seal with Degree

    Seal with Degree

    (Member, Medical Board)

    (Member, Medical Board)

    (Member, Medical Board)

    Signature/Thumb impression of Patient


    Countersigned by the
    Medical Superintendent/CMO/Head of Hospital (with seal)

    PWD Certificate Format

    Centralized Counselling forM.Tech./M.Arch./M.Plan. Admissions 2016


    (CCMT-2016)
    Coordinated by NITK, Surathkal

    PWD Certificate for Medical Board at RC


    (For the use of Medical Board at RC)
    Date ____________
    Name of the RC__________________________________________________________________________________________
    This is to certify that Shri/Smt/Kum___________________________________________________________________________
    Son / daughter of Shri _____________________________________________________________________________________
    age___________ sex_____________ identification mark (s)_______________________________________________________
    _______________________________________________________________________________________________________
    PN________ ______________ GATE Score ___________ Category __________ is suffering from permanent disability of following category:A. Locomotors or cerebral palsy:
    (i) BL-Both legs affected but not arms.
    (ii) BA-Both arms affected

    (a) Impaired reach


    (b) Weakness of grip

    (iii) BLA-Both legs and both arms affected


    (iv) OL-One leg affected (right or left)

    (a) Impaired reach


    (b) Weakness of grip
    (c) Ataxic
    (a) Impaired reach
    (b) Weakness of grip
    (c) Ataxic

    (v) OA-One arm affected

    (vi) BH-Stiff back and hips (Cannot sit or stoop)


    (vii) MW-Muscular weakness and limited physical
    endurance
    B. Blindness or Low Visio:
    (i) B-Blind
    (ii) PB-Partially Blind
    C. Hearing Impairment:
    (i) D-Deaf
    (ii) PD-Partially Deaf
    Percentage of disability is ______________ percent.
    This is to certify that the candidate is capable of carrying out all theory and practical requirement of engineering/technology/ architecture studies.
    and
    This is to certify that the persons from whom disability certificate the candidate has produced are authentic.
    Signature of the candidate ______________________
    (Dr._______________)
    Medical Board Member,

    (Dr._____________________)
    Medical Board Member,
    (Dr.___________________)
    Medical Board Chairperson, Medical Board

    (Dr.___________________)
    Medical Board Member

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