Application form for Certificate for Eligibility for Reservation for Other Backward Classes
(This form however should be used as a model additional items, if necessary, may be incorporate to suit to the local situation in the form)
To
Sir,
The Tehsildar
Jagadhri (Haryana)
I request that a certificate in respect of reservation of other Backward Classes in Civil and services under Govt of India be granted to me.
I give below the necessary particulars:-
I. Full Name of the Applicant
(In Block Lett=)
2. Date of Birth
3. Complete Residential Address
a) Present
b) Permanent
4. Religion
5. Caste
6. Sub-Caste
7. Occupation
8. Serial Number of the caate in
Central List ofOBC's
9. Name of Father
10. Name of Mother
II. Name ofHuaband
12. Status of Husband/Parents (s)
Father
a) Constitunal Posts
b) Designatioual
c) Governmental Services.
i) Service (Central/State)
ii) Designation
iii) Scale of pay including
Classification, if any
iv) Date of appointment to
the post
v) Age at the time of promotion
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to class I post (if Applicable) :-
11. Employeruent in lnternatioual
Organisation eg. UN, UNICEF,
UNO.
Mother Husband
i) Name of Organisation :-
ii) Designation :-
iii) Period of service
(indicate date from to _______ _
i) Death/Incapacitation (Omit if not applicable)
Putting officer out of service :-
ii) Details of permanent incapacitation.
C. Department in Public Sector undertaking etc.
i) Name of the Organisation
ii) iv) Date of appointment to the post-
D. Anns forces including Para-Military Forces.
(This will not inclode persons holding civil posts)
i) Designation
ii) Scale of Pay
E. Professional include persons holding civil covered
In NOS.S & Sand those engaged in Trade,
Business and Industry :-
i) Orgo. Profession :-
F. Property owners :-
L Agricultural Land Holding Owner by Mother,
Father, 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.
v) If any lying is both irrigated/
unirrigated total land
holding on the state laod ceiling law.
vi) Percentage in ceiling limit as per (iv)
E}-11- Plantation
i) Crops/fruit :-
ii) Location
iii) Area of plantation
F)-ill- Vacant landfor building in wban areas
Or urban applemention ....................................... .
i) Location of property :-
ii) Details of property :-
iii) Use of which it is put :-
G) Income/wealth
i) Annual family income from all sources
(Excluding salary & income from agricultural
land.)
ii) WhetherTaxPay(Yes/No)
(If yes a copy of the last three years return
be furnished).
iii) Whether covered in wealth Tax Act. (Yes/No)
H) Any other remarks :-