LIST OF FORMS

FORM – I FORMAT OF SC / ST CASTE CERTIFICATE

FORM – II FORMAT OF OBC CASTE CERTIFICATE

FORM – III FORMAT OF DECLARATION TO BE PRODUCED BY OBC CANDIDATES

FORM – IV DISABILITY CERTIFICATE (IN CASES OF AMPUTATION OR COMPLETE PERMANENT

PARALYSIS OF LIMBS AND IN CASES OF BLINDNESS)

FORM – V DISABILITY CERTIFICATE (IN CASE OF MULTIPLE DISABILITIES)

FORM – VI DISABILITY CERTIFICATE (IN CASES OTHER THAN THOSE MENTIONED IN FORM IV AND
V)
FORM - VII FORM OF CERTIFICATE APPLICABLE FOR RELEASED/RETIRED PERSONNEL FROM ARMY
/ NAVY / AIR FORCE
FORM – VIII FORM OF UNDERTAKING TO BE GIVEN BY THE EX-SERVICEMAN

FORM—IX EWS CERTIFICATE FORMAT

FORM --X SAMPLE FORMAT OF CHARACTER CERTIFICATE

 FORM – I
FORM OF CERTIFICATE TO BE PRODUCED BY A
CANDIDATE BELONGING TO SCHEDULED CASTE OR
SCHEDULED TRIBE IN SUPPORT OF HIS / HER CLAIM.

1. This is to certify that Sri / Smt / Kum*_______________________________________________ son / daughter*

of______________________________________________________ of village / town* ____________________________
in District / Division*_______________________of the State / Union Territory*__________________belongs to the
___________________Caste/Tribe* which is recognized as a Scheduled Caste/ Scheduled Tribe* under:
∗ The Constitution ( Scheduled Castes) Order, 1950 ;
∗ The Constitution ( Scheduled Tribes) Order, 1950 ;
∗ The Constitution (Scheduled Castes)(Union Territories)Orders, 1951 ;
∗ The Constitution (Scheduled Tribes)(Union Territories)Order, 1951 ;

[as amended by the Scheduled Castes and Scheduled Tribes lists Modification) Order,1956; the Bombay Reorganisation Act,
1960; the Punjab Reorganisation Act 1966, the State of Himachal Pradesh Act, 1970, the North-Eastern Areas
(Reorganisation)Act, 1971, the Constitution (Scheduled Castes and Scheduled Tribes) Order (Amendment) Act,1976, The State of
Mizoram Act, 1986, the State of Arunachal Pradesh Act, 1986 and the Goa, Daman and Diu (Reorganization) Act, 1987.]:

∗ The Constitution (Jammu and Kashmir) Scheduled Castes Order,1956 ;

∗ The Constitution (Andaman and Nicobar Islands) Scheduled
Tribes Order, 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 and Nagar Haveli) Scheduled Tribes Order, 1962 ;
∗ The Constitution (Pondicherry) Scheduled Castes Order 1964;
∗ The Constitution (Uttar Pradesh) Scheduled Tribes Order,1967;
∗ The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968 ;
∗ The Constitution (Goa, Daman and Diu) 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 (Jammu and Kashmir) Scheduled Tribes Order, 1989 ;
∗ The Constitution (Scheduled Castes) Orders (Amendment)Act, 1990;
∗ The Constitution (ST) Orders (Amendment) Ordinance, 1991 ;
∗ The Constitution (ST) Orders (Second Amendment) Act,1991 ;
∗ The Constitution (ST) Orders (Amendment) Ordinance, 1996;
∗ The Scheduled Caste and Scheduled Tribes Orders (Amendment) Act 2002;
*The Constitution (Scheduled Castes) Order (Amendment) Act, 2002;
*The Constitution (Scheduled Caste and Scheduled Tribes) Order (Amendment) Act, 2002;
*The Constitution (Scheduled Caste) Order (Second Amendment) Act, 2002].
 2 ::

2. Applicable in the case of Scheduled Castes / Scheduled Tribes persons, who have migrated from one State / Union
Territory Administration.

This certificate is issued on the basis of the Scheduled Castes / Scheduled Tribes* Certificate issued to Shri / Smt / Kumari*
_________________________________________Father /Mother* of Sri / Smt / Kumari*________________-
____________________________________of village / town______________________in
District/Division*____________________of the State/Union Territory*_________________________________ who belong to
the______________________ Caste / Tribe* which is recognized as a Scheduled Caste/Scheduled Tribe* in the State/Union
Territory* issued by the ____________________________________[Name of the authority] vide their order No.
___________________________ dated _______________________.

3. Shri/Smt/Kumari*____________________________________________and/or* his/her* family ordinarily reside(s) in

village/town*__________________________ of____________________ District / Division* of the State / Union Territory* of
_____________________

Signature _____________________

Designation ___________________

Place: [With seal of Office]

Date : State/Union Territory

Note : The term "Ordinarily resides" used here will have the same meaning as in Section 20 of the Representation of the Peoples
Act, 1950.
-----------------------------------------------------------------------------------------------------------------------------------------
* Please delete the words which are not applicable.
# Delete the paragraph which is not applicable.

List of authorities empowered to issue Caste / Tribe Certificates:

1. District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner / Additional Deputy
Commissioner / Deputy Collector/I Class Stipendiary Magistrate / Sub-Divisional Magistrate / Extra-Asst. Commissioner /
Taluka Magistrate / Executive Magistrate.

2. Chief Presidency Magistrate/ Additional Chief Presidency Magistrate / presidency Magistrate.

3. Revenue Officer not below the rank of Tehsildar.

4. Sub-Divisional Officers of the area where the candidate and / or his family normally resides.

Note : The Certificate is subject to amendment/modification of Scheduled Castes and Scheduled Tribes lists from time to time
-- -- --
 FORM - II
FORM OF CERTIFICATE TO BE PRODUCED BY
OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT
TO POSTS UNDER THE GOVERNMENT OF INDIA

This is to certify that Sri / Smt. / Kumari________________________________________________son/daughter of

__________________________________ of village/Town ____________________________District/Division
_______________ in the State/ Union Territory________________________ belongs to the
______________________________community which is recognized as a backward class under the Government of India,
Ministry of Social Justice and Empowerment’s Resolution No. __________________dated ___________*. Shri/Smt./Kumari
____________________and/or his/her family ordinarily reside(s) in the ______________________District/Division of the
__________________________State/Union Territory. 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 OM No.36012/22/93- Estt.[SCT], dated 8-9-1993 **.

Dated : District Magistrate

Deputy Commissioner etc.

Seal

* - the authority issuing the certificate may have to mention the details of Resolution of Government of India, in
which the caste of the candidate is mentioned as OBC.
**- As amended from time to time.

Note:- The term “Ordinarily” used here will have the same meaning as in Section 20of the Representation of the
People Act, 1950.
The Prescribed proforma shall be subject to amendment from time to time as per Government of India Guidelines.
 FORM - III

Form of declaration to be submitted by the OBC candidates (in addition to the Community Certificate)

I ………………………………………………. Son / daughter of Shri ……………………………………………………………………….. resident of village / town

/city ……………………………………… district …………………………………………. State …………………………….. hereby declare that I belong to the

…………………………………………………………. Community which is recognized 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.

3610222/93-Estt (SCT) dated 08/09/1993. It is also declared that I don’t belong to persons / sections / (Creamy Layer)

mentioned in column 3 of Schedule to the above referred Office Memorandum dated 08/09/1993, O.M. No. 36033/3/2004-Estt

(Res) dated 09th March 2004 and O.M. No. 36033/3/2004-Estt (Res) dated 14th October, 2008.

Signature of the Candidate ……………………………………….

Full Name ………………………………………………………………….

Address……………………………………………………………………..
 FORM-IV
Disability Certificate
(In cases of amputation or complete permanent paralysis of limbs and in cases of blindness)
(Prescribed proforma subject to amendment from time to time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent PP size
Attested
Photograph
(Showing face
only) of the
person with
disability

Certificate No. : Date :

This is to certify that I have carefully examined

Shri/Smt./Kum. _____________________________________________________________ son/wife/daughter of Shri

___________________________________________________ Date of Birth (DD / MM / YY) ____ ____ ____
Age ________ years, male/female Registration No. __________________________ permanent resident of House
No.______________________ Ward/Village/Street ___________________________________________ Post Office
___________________________________District __________ State ____________, whose photograph is affixed
above, and am satisfied that :

(A) he/she is a case of :

• Iocomotor disability
• Blindness
(Please tick as applicable)
(B) The diagnosis in his/her case is _________
(C) He/She has ______________% (in figure) ________________________ percent (in words) permanent physical
impairment/blindness in relation to his/her _________ (part of body) as per guidelines (to be specified)
2. The applicant has submitted the following documents as proof of residence :-
Nature of Document Date of Details of authority issuing certificate

Issue

(Signature and Seal of Authorised Signatory of notified Medical Authority)

Signature/Thumb
impression of the
person in whose
favour disability
certificate is issued.
 FORM - V
Disability Certificate
(In case of multiple disabilities)
(Prescribed proforma subject to amendment from time to time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent PP size
Attested
Photograph
(Showing face
only) of the
person with
disability

Certificate No. : Date :

This is to certify that we have carefully examined

Shri/Smt./Kum. _____________________________________________________________ son/wife/daughter of Shri

___________________________________________________ Date of Birth (DD / MM / YY) ____ ____ ____
Age ______ years, male/female ___________ Registration No. __________________________ permanent resident of
House No.______________________ Ward/Village/Street ___________________________________________ Post
Office ___________________________________District __________ State ____________, whose photograph is
affixed above, and are satisfied that :

(A) He/she is a Case of Multiple Disabilities. His/her extent of permanent physical impairment/disability has been
evaluated as per guidelines (to be specified) for the disabilities ticked below, and shown against the relevant disability in the
table below :

Permanent
Sr.
Affected Part of physical
No.
Disability Body Diagnosis impairment/mental disability (in %)

1 Locomotor disability @
2 Low vision #

3 Blindness Both Eyes

4 Hearing impairment £

5 Mental retardation X

6 Mental-illness X

(B) In the light of the above, his/her over all permanent physical impairment as per guidelines (to be specified), is as follows
:-

In figures :- ____________________ percent

In words :- __________________________________________________________________ percent

2. This condition is progressive/non-progressive/likely to improve/not likely to improve.

3. Reassessment of disability is :

not necessary,

Or
(i) is recommended / after __________ years __________ months, and therefore this certificate shall be valid till (DD / MM
/ YY) ____ ____ ____
@ - e.g. Left/Right/both arms/legs

# - e.g. Single eye / both eyes

£ - e.g. Left / Right / both ears

4. The applicant has submitted the following documents as proof of residence :-

Nature of Document Date of Details of authority issuing certificate

Issue

5. Signature and Seal of the Medical Authority

Name and seal of Member Name and seal of Member Name and seal of Chairperson

Signature/Thumb
impression of the
person in whose
favour disability
certificate is issued.
 FORM - VI
Disability Certificate
(In cases other than those mentioned in Form IV and V)
(Prescribed proforma subject to amendment from time to time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent PP size
Attested
Photograph
(Showing face only)
of the person with
disability

Certificate No. : Date :

This is to certify that I have carefully examined

Shri/Smt./Kum. _____________________________________________________________ son/wife/daughter of Shri

___________________________________________________ Date of Birth (DD / MM / YY) ____ ____ ____
Age ________ years, male/female __________Registration No. __________________________ permanent resident
of House No.______________________ Ward/Village/Street ___________________________________________
Post Office ___________________________________District __________ State ____________, whose photograph is
affixed above, and am satisfied that he/she is a Case of _________________________ disability. His/her extent of
percentage physical impairment/disability has been evaluated as per guidelines (to be specified) and is shown against
the relevant disability in the table below :

Sr. Disability Affected Part of Diagnosis Permanent physical

No. Body impairment/mental disability (in %)

1 Locomotor disability @

2 Low vision #

3 Blindness Both Eyes

4 Hearing impairment £

5 Mental retardation X

6 Mental-illness X

(Please strike out the disabilities which are not applicable.)

2. The above condition is progressive/non-progressive/likely to improve/not likely to improve.

3. Reassessment of disability is :

(i) not necessary,

Or

(ii) is recommended / after __________ years __________ months, and therefore this certificate shall be valid till (DD / MM
/ YY) ____ ____ ____

@ - e.g. Left/Right/both arms/legs

# - e.g. Single eye / both eyes £ -

e.g. Left / Right / both ears

4. The applicant has submitted the following documents as proof of residence :-

Nature of Document Date of Details of authority issuing certificate

Issue

(Authorised Signatory of notified Medical Authority)

(Name and Seal)
Countersigned
{Countersignature and seal of the
CMO/Medical Superintendent/Head of
Government Hospital, in case the
certificate is issued by a medical
authority who is not a government
servant (with seal)}

Signature/Thumb
impression of the
person in whose
favour disability
certificate is issued.
 FORM - VII

Form of Certificate applicable for Released/Retired Personnel

(Prescribed proforma subject to amendment from time to time)

It is certified that No. ____________ Rank __________ Name _______________________
whose date of birth is __________ has rendered service from _________ to________ in
Army/Navy/Air Force.

2. He has been released from military services :

% a) on completion of assignment otherwise than

(i) by way of dismissal, or

(ii) by way of discharge on account of misconduct or inefficiency, or

(iii) on his own request, but without earning his pension, or

(iv) he has not been transferred to the reserve pending such release.

%b) on account of physical disability attributable to Military Service.

%c) on invalidment after putting in at least five years of Military service

3. He is covered under the definition of Ex-Serviceman (Re-employment in Central Civil Services and Posts) Rules, 1979 as
amended from time to time.

Place : Signature, Name and Designation of the

Competent Authority **

Date:
SEAL

% Delete the paragraph which is not applicable.

** Authorities who are competent to issue certificate to Armed Forces Personnel for availing Age concessions are as
follows :

(a) In case of Commissioned Officers including ECOs/SSCOs: Army: Military Secretary Branch, Army Hqrs., New Delhi; Navy :
Directorate of Personnel, Naval Hqrs., New Delhi; Air Force : Directorate of Personnel Officers, Air Hqrs., New Delhi.

In case of JCOs/ORs and equivalent of the Navy and Air Force : Army : By various Regimental Record Offices; Navy : CABS,
Mumbai; Air Force : Air Force Records, New Delhi.
 FORM -VIII

UNDERTAKING TO BE GIVEN BY THE EX-SERVICEMAN

I understand that, if selected on the basis of recruitment/examination to which the application relates, my
appointment will be subject to my producing documentary evidence to the satisfaction of the Appointing
Authority that I have been duly released/retired/discharged from the Armed Forces and that I am entitled
to the benefits admissible to Ex-Servicemen in terms of the Ex-Servicemen (Re-Employment in Central
Civil Services and Posts rules, 1979, as amended from time to time).

I also understand that I shall not be eligible to be appointed to a vacancy reserved for Ex-S in regard to
the recruitment covered by this examination, if I have at any time prior to such appointment, secured any
employment on the civil side (including Public Sector Undertaking, Autonomous Bodies/Statutory Bodies,
Nationalized Banks, etc.) by availing of the concession of reservation of vacancies admissible to Ex-S.

I further submit the following information:

a) Date of appointment in Armed

Forces
b) Date of discharge

c) Length of service in Armed Forces

d) My last Unit/Corps

Place:

Date:
(Signature of the Candidate)
 CHARACTER CERTIFICATE

This is to certify that Mr/Ms …………………………………………………… S/o ………………….

is the resident of ……………………………………………………………………………………….

and is known to me since ………….. years. He/She hails from a respectable family

During the above tenure ,his character and conduct is found to be ………

Place:

Date : SIGNATURE WITH STAMP