..

PROFORMA-1
for

Residential/Domicile Certificate for both ANM(R) & GNM course

for
permanent residents of the Gram Panchayet area of the concerned District of
West Bengal (from where the candidate applies) uninterruptedly for at least
five preceding years till 31.12.2021.

I hereby certify that I personally know Ms. …………………………………………………………………….

D/o, …………………………………………………………, W/o, ……………………………………………….…………,

She is a citizen of India and has been residing in the Gram Panchayet area in the district of
……………………………………………………………. in West Bengal for at least five years till 31.12.2021.

Her present address is …..…………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………..…

…………………………………………………………………………………………………………………………………………

Candidate’s signature

Paste 4 cmx3 cm
size recent colour Candidate must sign here in front of the
photograph in this certifying authority.
box

(Candidate’s Photograph)

_______________________________________________
Signature of Certifying Authority with date and office seal
 PROFORMA-2
for

Residential/Domicile Certificate for only GNM course

for
permanent residents of the District of West Bengal (from where the candidate
applies) uninterruptedly for at least five preceding years till 31.12.2021.

I hereby certify that I personally know Ms. …………………………………………………………………….

D/o, …………………………………………………………, W/o, ……………………………………………….…………,

She is a citizen of India and has been residing in the district of …………………………………………….

in West Bengal for at least five years till 31.12.2021.

Her present address is …..…………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………..…

…………………………………………………………………………………………………………………………………………

Candidate’s signature
Paste 4 cmx3 cm
size recent colour
photograph in this Candidate must sign here in front of the
box certifying authority.

(Candidate’s Photograph)
_______________________________________________
Signature of Certifying Authority with date and office seal
 PROFORMA-3
for Candidate’s
Medical Fitness Certificate for photograph,
attested by the
ANM (R) & GNM courses Medical
Practitioner

(A) Personal information:

1. Candidate’s name (in BLOCK letters): _________________________________________________

2. Father’s /Guardian’s name: ____________________________________________________________

3. Date of birth: ___________________________

4. Present address: _______________________________________________________________________

_________________________________________________________________________

________________________________________________________________________

5. Permanent address: ____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

(B) History of illness:

1. Past and present illness:

2. Family history:

(C) Physical examination:

1. Height:
2. Physical built:

3. Deformity:

4. Posture and gait:

5. Condition of skin and mucous membrane:

6. Teeth and gum

7. Hearing:

8. Mental alertness:

9. Blood pressure

10. Pulse and respiration

11. Urine test for Albumin and Sugar:

12. Blood test for TC, DC, ESR and Hb%:

13. Vision: Right eye: Left eye:

14. Heart:

15. Lung (X-ray chest):

16. Abdomen (Liver and Spleen)

17. Menstrual History (For female candidates):

(D) “I hereby certify that I have examined Mr./Ms. _____________________________________, a

candidate for ANM(R)/GNM training course and I couldn’t discover that he/she has

any disease (communicable or otherwise), constitutional weakness or bodily

infirmity, except _____________________________________. I do not consider this a

disqualification for the said training.

According to the statement of Mr./ Ms. _____________________________________, he/ she is

___________________year old and by appearance he/ she is about ____________________year old”.

In view of the above findings, the candidate is

a) FIT OR

b) Unfit on account of ________________________________________________ _________________ OR

c) Temporarily unfit on account of ___________________________________________________

_____________________________________________
Full signature of the candidate with date

___________________________________________
Place: Signature of the Medical Practitioner

Date: Name:

Degree:

Registration No.

Official seal:
 Certificate regarding physical limitation to write in an examination.
Certificate No. ……………………………… Dated …………… Paste 4 cmx3
This is to certify that Mr./Ms. …………………………………………………………… cm size recent
colour
Son/daughter of Mr. Ms. ………………………………………………………………….. photograph of
Residing at ………………………………………………………..………………………………….. the candidate
in this box.
………………………………………………………………………………………………..
Having WBJEE-2021 application No. ………………………………….……… has the following disability
(name of the Specified Disability)
………………………………………………………………………………………………. In percentage of
…………………………………………………(in words) ……………………………………..(in figures).
Please tick the specified disability (Assessment may be done on the basis of Gazette of India,
Extraordinary, Part-II, Section-3, Subsection (ii)) Ministry of Social Justice and
Empowerment)
S. Category Type of Disability Specified Disability
No.
1 Physical Locomotor a) Leprosy cured person,
Disability Disability b) Cerebral palsy,
c) Dwarfism,
d) Muscular dystrophy,
e) Acid attack victims
Visual Impairment a) Blindness,
b) Low vision
Hearing Impairment a) Deaf,
b) Hard of hearing
Speech & Language a) Permanent disability arising out of conditions
Disability such as laryngectomy or aphasia affecting one
or more components of speech and language
due to organic or neurological causes
2 Intellectu a) Specific learning Disability (Perceptual
al Disabilities, Dyslexia, Dyscalculia, Dyspraxia &
Disability Development Aphasia)
b) Autism spectrum disorder
3 Mental a) Mental illness
Behaviour
4 Disability i. Chronic a) Multiple sclerosis
caused due Neurological b) Parkinsonism
to Conditions
ii.Blood disorder a) Haemophilia,
b) Thalassemia,
c) Sickle cell disease
5 Multiple a) More than one of the above specified
Disabilities disabilities including deaf blindness
This is to furthet certify that he /she has physical limitation which hampers his/her writing
capabilities to write the examination owing to his/her disability.
Signature
Name
Chief Medical Officer/ Civil Surgeon/Medical Superintendent
Govt. Health Care Institution with seal
 Letter of Undertaking for Using Own Scribe

I……………………………………………………….., a candidate with…………………………………………………..

(name of the disability) appearing for the ………………………………………………………………………………

(name of the examination) bearing Application No. ……………………………………….. do hereby state

that …………………………………………………………………………………….. (name of the scribe) will provide

the service of scribe/reader for the undersigned for taking the aforesaid examination.

I do hereby undertake that his qualification is ………………………………………….

Signature of the candidate Paste 4 cmx3

cm size recent
colour
Name of the scribe: …………………………………………………
photograph of
ID of the scribe: …………………………………………………………. the scribe in
ID number: ………………………………………………………………. this box.
 Recommended format for NCL Certificate

RECOMMENDED FORMAT OF CERTIFICATE TO BE PRODUCED BY NON-

CREAMY LAYER (NCL) OTHER BACKWARD CLASSES CANDIDATES

Certificate No. - Date:

This is to certify that Son/daughter of_________________________________

of village _____________________ P.O. P.S. ________________________

in the district of in West Bengal belongs to the community which is

recognized as a Backward Class (Other Backward Class - Category A/B) by the Government of West

Bengal, under: __________________________________ and as a Backward Class by the Government of

India for the State of West Bengal under: and his/her family are

permanent resident(s) in the District of in West Bengal.

This is also to certify that he does not belong to the category of persons/section (Creamy Layer) to
whom reservation shall not apply as provided in Schedule II under Section 4 of the West Bengal
backward Classes (other than Scheduled Castes and Scheduled Tribes) (Reservation of Vacancies in
Services and Posts) Act, 2012 or in Column No. 3 of the Schedule to the Govt. of India, Department of
Personnel & Training O.M. No. 36012/22/93-Estt (SCT) Dated 8-9-93, last revised vide O.M.No.
36033/1/2013 dated the 27th May, 2013.

Applicant’s
recent passport
size Signature of issuing Officer
photograph Office District Magistrate/ Executive Magistrate/ Add. District
duly attested seal Magistrate/ S.D.M./ Tehsildar /Sub Divisional Officer

District ……………………….
West Bengal

OBC-A / OBC-B Certificate issuing authority for candidates claiming under such reserve category of seats are as per Notification vide No.
374(71)-TW/EC/MR-103/94 dated 27/7/1994, read with Memorandum No. 1204-SBCW/MR-67/10 dated 27/7/2015 issued by Backward
Classes Welfare Department. Govt. of W.B., the Sub Divisional Officer of a Sub- Division in a District is t h e certificate issuing authority.
In Kolkata such certificate is issued by such an officer as the State Government by modification authorizes. Accordingly, the District Welfare
Officer, Kolkata, and Ex-officio Joint Director, BCW has been notified to act as the certificate issuing authority in respect of Kolkata
covering the jurisdiction of the Kolkata Municipal Corporation.

THE CERTIFICATE MUST HAVE BEEN ISSUED IN THE CURRENT FINANCIAL YEAR WHEN IT IS PRODUCED FOR VERIFICATION