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applicationdetails (3)

This document is an online application form for obtaining a Scheduled Caste (SC) or Scheduled Tribe (ST) certificate, submitted by Atish Mondal for the DhoBa caste. The application includes personal details such as the applicant's name, father's name, date of birth, address, nationality, religion, and contact information. It also mentions the applicant's father's existing caste certificate and provides details of two referees.

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Anindya Mandal
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6 views

applicationdetails (3)

This document is an online application form for obtaining a Scheduled Caste (SC) or Scheduled Tribe (ST) certificate, submitted by Atish Mondal for the DhoBa caste. The application includes personal details such as the applicant's name, father's name, date of birth, address, nationality, religion, and contact information. It also mentions the applicant's father's existing caste certificate and provides details of two referees.

Uploaded by

Anindya Mandal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM IA

SEE RULE 7BB[I]


FORM OF ON LINE APPLICATION FOR SCHEDULED CASTE / SCHEDULED TRIBE CERTIFICATE
To
The Sub-Divisional Officer / D.W.O, Kolkata & Ex-Officio Joint Director, B.C.W,
Diamond Harbour , South 24 Parganas.
Sir,
I do hereby apply for SC/ST Certificate in the following prescribed proforma, for which particulars are
given below. I hereby undertake that the information is correct to the best of my knowledge and belief and
if anything found contrary I would be liable for that.

Yours faithfully,
Date:
(Signature of applicant / gurdian in case of minor)
Application No : SCWB18032025/993 ( Block : Diamond Harbour-II )
1. (a) Applying for : SC (b) Name of caste : DHOBA
2. Full Name of Applicant : ATISH MONDAL
: Father's Name
3. : TAPAS MONDAL 5. Contact No. : 9932225813
4. (a) Date of Birth : 05/07/2010 6. Email Id. :
(b) Place of Birth : 7. Aadhaar No. : XXXXXXXX9904
Village / Ward Police Station District State
KALAGACHIA DIAMOND HARBOUR SOUTH 24 PARGANAS WEST BENGAL

8. Address since birth (a) Present address:


Para / House No. / Ward No. / G.P. Post Office Police Station District State PIN
Road / Village
KALAGACHIA SARISHA SARISHA DIAMOND SOUTH 24 WEST 743368
HARBOUR PARGANAS BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
KALAGACHIA SARISHA SARISHA SOUTH 24 WEST 743368
PARGANAS BENGAL

9. Nationality : INDIAN 10. Religion : Hinduism 11. Sex : Male


12. Whether any of the blood relations of the applicant posseses Caste Certificate? Yes
If answer to point no. 12 is 'Yes':
Name of cert. holder Relation with applicant Certificate No. Date of Issue Issuing authority
TAPAS MONDAL FATHER DS 14/11/2006 DIAMOND HARBOUR

13. Details of two(2) referees:


Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
MITTUNJAI BAIRAGI VILL-KALAGACHIA, P.O- AJAY BAIRAGI VILL-KALAGACHIA, P.O-
SARISHA, P.S- DIAMOND SARISHA, P.S-
HARBOUR No DIAMOND
14. Whether the applicant or his HARBOUR
family migrated from other State / Cou
If point no. 14 is 'Yes': Migration Certificate No. : Date of Issue :
Address of the applicant in his/her state of origin.
Village / Ward Police Station District State Country Year

Date: ( Signarure of applicant / gurdian in case of minor )

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