Annexure-II   Central

Application form for OBC certificate for eligibility for reservation or jobs for other backward classes in civil posts and services.

(This form, however, should be used only as a model. Additional items, if necessary, may be incorporated to suit to the local situation in the form).

To

   -----------------------------

   -----------------------------

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 have given below 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 number of the caste in the central list of OBCs

:-

9. Father’s Name

:-

10. Mother’s Name

:-

11. Husband’s Name

:-

 

 

 

 

12. Status of parents/husband :                               Father                                     Mother

(A) Constitutional posts       

:-

i. Designation

:-

(B) Government 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 to Class-I post           

                       (if applicable)

:-

II. Employment in International organization e.g. 

    UN. UNICEF, WHO

 

i. Name of Organization

:-

ii. Designation

:-

iii. Period of Service(indicate date)

:-

III. Death/permanent incapacitation

          (omit if not applicable)

 

i. Date of death/permanent incapacitation

:-

ii. Putting an officer out of service  

:-

iii. Details of permanent incapacitation

:-

(C) Employment in public sector under takings etc.

 

i. Name of organisation       

:-

ii. Designation

:-

iii. Date of appointmnet to the post

:-

(D) Armed forces including – para-military forces

    (This will not include persons holding civil posts)

 

i. Designation

:-

ii. Scale of pay

:-

Professional class (other than these covered in item nos. B & C) and those engaged in trade, business and industry) :

Occupation/profession

:

 

 

(F)       Property owners

F(I)      Agricultural land holding: owned by mother, father & minor children

i. Location

:-

ii. Size of holding

:-

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

 

(i)

 

(ii)

 

(iii)

 

(b) Un-irrigated

 

 

To be certified by District Revenue Officer not lower than the rank of Tehsilder.

 

                  (iv)           Percentage of irrigated land holding to statutory   ceiling limit under state land ceiling lows.

                    (v)           If land holding is both irrigated/unirrigated total irrigated land holdings on the basis of conversion formula in state land ceiling law.

                  (vi)           Percentage of total irrigated land holding to statutory ceiling limit as per (iv)

F(II). Plantation

(i) Crops/fruit

:

(ii) Location

:

(iii) Area of plantation

:

 

F(III). Vacant land or building in urban areas or urban agglomeration

(i) Location of property

:

(ii) Details of property

:

(iii) Use to which if is put

:

 

(G) Income/wealth

(i) Annual family income from all sources(excluding salaries & income from agricultural land)

:

(ii) Whether tax payer(Yes/No)

(if yes, a copy of the last three years return be furnished)

:

(iii) Whether covered in wealth TaxAct (Yes/No)

                    (if so furnish details)

:

1.      Any other remarks                                                           :

:

 

 

 

 

 

 

2. I certify that 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 eligible to be considered for posts reserved for OBCs. In the event of any information being found false or incorrect or in eligibility being detected before or after the 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,

 

 

Date                                                                                        (Signature of the candidate)

 

 

 

 

Enquiry report for issuing OBC certificate.

 

1. Name of the applicant     

:-

2. Father’s name of applicant

:

2.      Present address

 

:-

3.      Permanent address

 

:-

5. Date of Birth

:-

6. Educational Qualification

:-

7. Name of post applied for

:-

8. Nationality Certified

:-

9. Name of the caste to which applicant or father belongs with no. & date of caste certifcate if any

:-

11. Total family income from all sources :                          Father                                    Mother

12. If parents employed nature of service  :                        Post hold                               Total salary

13. Particulars of land owned by applicant/family

:-

14. Total agricultural land (including plantation)

:-

      Total non-agricultural land

(verify from Revenue record and field enquiry)

:-

15. Observation of the enquiring officer, with specific comments about caste to which the applicants belongs

:-

 

On enquiry, I am satisfied that the applicant belongs to ……………… community, which is recognized as other backward class in Tripura.

OBC certificate may be/may not be issued to the applicant.

 

 

 

Signature of the enquiry Officer

With seal

 

 

 

 

 

14.       Observation of the Inspector/Supervisor (TW/SCW) with specific comments about the caste to which the applicant belongs:

 

On scrutiny of the enquiry report submitted by Tehsilder and on further enquiry conducted by me, I am satisfied that the applicant belongs/does not belongs to the ……………………………………. Community, which is recognised as other backward class in Tripura.

 

OBC certificate may be may not be issued to him/her.

 

 

 

 

Signature of Inspector/Supervisor

(TW/SCW) with seal

 

15.       Case recommended/not recommended by the Sub-divisional Committee on OBC, vide their resolution no. ………………dated……………

 

 

 

 

Dealing Assistant

OBC section

 SDM office.

 

 

 

 

16.       Observation of Dy. Collector, Revenue Circle/Branch Officer, TW section, SDM office.

 

On scrutiny of the enquiry report of Tehsilder/Inspector/Supervisor (TW/SCW) and  documents produced by the applicant and recommendations of the Sub-Divisional OBC Committee, I am satisfied/not satisfied that:

 

1. The  applicant  belongs/does not  belongs  to the ………………………………..community, which is recognised as other backward class in Tripura.

 

2.  And the applicant does not belong/belong to the persons/section included in the Creamy Layer as notified by the Government.

 

 

 

SDTWO/ Spl. Officer (TW) / DC (Rev)

 

 

ANNEXURE-II

 

APPLICATION FORM FOR O.B.C. CERTIFICIATE

 

 

To

The Sub-Divisional Officer

______________________

 

 

Sub:    Prayer for O.B.C. Certificate (for purposes other than Government Job)

 

Sir,

            I beg to state that I am a member of the Other Backward Classes of Tripura as approved by the Government of Tripura vide Notification No.F.6-74/SCW/STAT/94/4899-5010 dated 8th March,1995.

           

I shall be grateful if you kindly issue me an O.B.C. Certificate. Necessary particulars are given below:-

 

1. Full name of the Applicant

     (In block letter)

:-

2. Name of the Father/Husband

:-

3. Date of birth

:-

4. Complete residential address

:-

a)     Present

 

:-

b)     Permanent

 

:-

5. Religion

:-

6. Caste

:-

7. Sub-Caste

:-

8. Whether a permanent resident of Tripura

-

9. Whether a citizen of India

:-

10. Present Occupation

:

11. Annual monthly income from all sources

 

 

 

:-

12. Name and address of the responsible person of the locality who belongs to O.B.C.                         

:-

13. Any other remark

:-

         

I hereby declare that the above mentioned particulars are true to the best of my knowledge and in the event of any information being found false or incorrect at any subsequent stage, the O.B.C. Certificate is liable to be cancelled and I shall be liable to any action as per provisions of law.

 

 

Date :                                                                                                  Yours faithfully,

 

 

 

Place:                                                

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of the Candidate

 

Certified that the applicant Sri/ Smti …………………………….Sri/ Smti………….

 

……………………………………S/O,D/O,W/O…………………………………….

 

has been known to me for the last……………………..years. He/She belongs to

 

………………………Community of the Other Backward Classes of Tripura.

 

 

 

 

Date  :                                                                         Signature and designation if any

of the person mentioned at Col. No.12 of the application form.

Place:                                              

 

Enclo :

1.

 

2.

 

3.

 


 

 

ENQUIRY REPORT FOR ISSUING OF OBC CERTIFICATE

 

1. Name of the applicant

:-

2. Father’s name of applicant

:-

3. Present address

 

:-

4. Permanent address

:-

5. Date of Birth

:-

6. Educational qualification

:-

7. Name of post applied for

:-

8. Nationality certificate

:-

9. Name of the caste to which applicant or father belongs with No. & date of caste certificate (if any)           

:-

10. Total family income from all sources :  Father                         Mother

 

11. If parents employed nature of service :            Post held                    Total salary

 

12. Particulars of land owned by applicant/family.

:-

(a) Total agri. Land (including Plantation)

:-

(b) Total non-agri land (verify from revenue record and field enquiry)

:-

13. Observation of the enquiring officer, with specific    

   comment’s about caste to which the applicant belongs

:-

 

On enquiry, I am satisfied that the applicant belongs to______________ community, which is recognized as other backward class in Tripura.

           

OBC certificate may be/may not be issued to the applicant.

 

 

 

 

Signature of the enquiry officer

     With seal

 

 

 

 

 

 

 

 

 

 

 

14. Observation of the Inspector/Supervisor (TW/SCW) with specific comments 

       about the caste to which the applicant belongs:

 

On scrutiny of the enquiry report submitted by Tehsildar and on further enquiry conducted by me, I am satisfied that the applicant belongs/does not belongs to the________________________ community which is recognized as other backward class in Tripura.

 

OBC certificate may be/may not be issued to him/her.

 

 

 

 

Signature of Inspector/Supervisor

                    (TW/SCW)

                                             With seal

 

15. Case recommended/not recommended by the Sub-Divisional Committee

      on OBC vide their resolution No.__________________________ 

       dated_________________________

 

 

Dealing Assistant

OBC Section, SDM’s office

 

16. Observation of Dy. Collector, Revenue circle/Branch Officer T.W section, SDM’s office.

 

On scrutiny of the enquiry report of Tehsildar/Inspector/Supervisor (TW/SCW) and documents produced by the applicant and recommendations of the Sub-Divisional OBC committee, I am satisfied/not satisfied that:

 

a)     The applicant belongs/does not belongs to the_________________community, which is recognized as other backward class in Tripura.

 

            b) And the applicant does not belong/belong to the persons/ section included in the ‘Creamy Layer’ as notified by the Government.

 

 

SDTWO/SPL. OFFICER(TW)/DC(REV)