FORMAT FOR OBC [NCL] CERTIFICATE

[This certificate MUST have been issued on or after 1st April 2020]

This is to certify that Shri/Smt./Kum. Son/Daughter of Shri/Smt.

of Village/Town

District/Division in the State/UT

belongs to the Community which is recognized as a backward class under:

(i) Resolution No. 12011/68/93-BCC(C), dated 10/09/93 published in the Gazette of India
Extraordinary Part I Section I No. 186, dated 13/09/93.
(ii) Resolution No. 12011/9/94-BCC, dated 19/10/94 published in the Gazette of India
Extraordinary Part I Section I No. 163, dated 20/10/94.
(iii) Resolution No. 12011/7/95-BCC, dated 24/05/95 published in the Gazette of India
Extraordinary Part I Section I No. 88, dated 25/05/95.
(iv) Resolution No. 12011/96/94-BCC, dated 9/03/96.
(v) Resolution No. 12011/44/96-BCC, dated 6/12/96 published in the Gazette of India
Extraordinary Part I Section I No. 210, dated 11/12/96.
(vi) Resolution No. 12011/13/97-BCC, dated 03/12/97.
(vii) Resolution No. 12011/99/94-BCC, dated 11/12/97.
(viii) Resolution No. 12011/68/98-BCC, dated 27/10/99.
(ix) Resolution No. 12011/88/98-BCC, dated 6/12/99 published in the Gazette of India
Extraordinary Part I Section I No. 270, dated 06/12/99.
(x) Resolution No. 12011/36/99-BCC, dated 04/04/2000 published in the Gazette of India
Extraordinary Part I Section I No. 71, dated 04/04/2000.
(xi) Resolution No. 12011/44/99-BCC, dated 21/09/2000 published in the Gazette of India
Extraordinary Part I Section I No. 210, dated 21/09/2000.
(xii) Resolution No. 12016/9/2000-BCC, dated 06/09/2001.
(xiii) Resolution No. 12011/1/2001-BCC, dated 19/06/2003.
(xiv) Resolution No. 12011/4/2002-BCC, dated 13/01/2004.
(xv) Resolution No. 12011/9/2004-BCC, dated 16/01/2006 published in the Gazette of India
Extraordinary Part I Section I No. 210, dated 16/01/2006.
(xvi) Resolution No. 12015/2/2007-BCC, dated 18/08/2010.
(xvii) Resolution No. 12015/2/2007-BCC, dated 11/10/2010.
(xviii) Resolution No. 12015/13/2010-BC-II, dated 08/12/2011.
(xix) Resolution No. 12015/05/2011-BC-II, dated 17/02/2014.
(xx) Resolution No. 12011/6/2014-BC-II, dated 07/12/2016.
(xxi) Resolution No. 12011/13/2016-BC-II, dated 22/12/2016
(xxii) Resolution No. 20012/1/2017-BC-II, dated 19/01/2017
(xxiii) Resolution No. 12011/7/2017-BC-II, dated 31/07/2017

Shri/Smt./Kum. and/or his family ordinarily reside(s) in the

District/Division of State/UT. 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 O.M. No. 36

012/22/93-Estt.(SCT), dated 08/09/93 which is modified vide OM No. 36033/3/2004 Estt.(Res.), dated

09/03/2004, further modified vide OM No. 36033/3/2004-Estt. (Res) dated 14/10/2008, again further

modified vide OM No. 36036/2/2013-Estt (Res) dated 30/05/2014.

Place Signature

Date Designation

(with seal of office)

NOTE:

(a) The term ‘Ordinarily’ used here will have the same meaning as in Section 20 of the
Representation of the People Act, 1950.
(b) ^The authorities competent to issue Caste Certificates are indicated below:
(i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner /
Additional Deputy Commissioner / Deputy Collector / First Class Stipendiary Magistrate
/ Sub-Divisional magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant
Commissioner (not below the rank of 1ST Class Stipendiary Magistrate).
(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency
Magistrate.
(iii) Revenue Officer not below the rank of Tehsildar.
(iv) Sub-Divisional Officer of the area where the candidate and / or his family resides.

(C) OBC Certificate issued from Maharashtra State must be validated by the Social Welfare
Department of Maharashtra Government.
 FORM-GEN-EWS

Government of ………………………………….
(Name & Address of the authority issuing the certificate)

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER

SECTIONS

Certificate No. Date:

VALID FOR THE YEAR _

1. This is to certify that Shri/Smt./Kumari son/daughter/wife of

permanent resident of ,
Village/Street Post Office District in
the State/Union Territory Pin Code _ whose photograph in attested
below belongs to Economically Weaker Sections, since the gross annual income* of his/her
“family”** is below Rs. 8 lakh (Rupees Eight Lakh only) for the financial year . His/her
family does not own or possess any of the following assets***:

I. 5 acres of agricultural land and above;

II. Residential flat of 1000 sq. ft. and above;
III. Residential plot of 100 sq. yards and above in notified municipalities;
IV. Residential plot of 200 sq. yards and above in areas other than the notified municipalities.

2. Shri/Smt./Kumari belongs to the caste which is not

recognized as a Schedule Caste, Schedule Tribe and Other Backward Classes (Central List).

Signature with seal of Officer

Name
Designation

Recent Passport size

attested photograph The income and assets of the families as mentioned
of the applicant would be required to be certified by an officer not
below the rank of Tehsildar in the States/UTs.

* Note1: Income covered all sources i.e. salary, agricultural, business, profession, etc.

** Note2: The term “Family” for this purpose include the person, who seeks benefit of reservation, his/her
parents are siblings below the age of 18 years as also his/her spouse and children below the age of 18 years.

*** Note3: The property held by a “Family” in different locations or different places/cities have been clubbed
while applying the land or property holding test to determine EWS status.
Undertaking by candidates who have appeared for qualifying degree
examination or awaiting for results

I, ___________________________________ ____ (Application ID_________________),

son/daughter of Shri -----------------------------------------------------------, resident of

village/town/city district of State/UT ________________do hereby declare as under:
1. That I have appeared for final year /semester examination and my Institute/University
has not yet declared the results
or
My university/Institute has not conducted final year /semester examination yet
(tick as applicable).

2. That, I would submit my final year/semester marks card and Provisional degree certificate
on or before ------------.

3. I am aware that for admission to Ph.D programmes at NITK, I must satisfy the following
criteria

“Candidate should have passed the prescribed qualifying degree in relevant field with a Cumulative
Grade Point Average (CGPA) of at least 6.0 in the 0-10 scale grading system, or not less than 60%
marks in the aggregate (taking into account the marks scored in all the subjects of all the public/
university examinations conducted during the entire prescribed period for the qualifying degree).
However, this prescribed minimum shall be a CGPA of 5.5 or 55% marks in the aggregate for
SC/ST/PwD candidates.

4. I am also aware that after the announcement of my Post graduate degree results, if I am
found not to satisfy the above eligibility criteria, my admission would be cancelled and I will
not be entitled for refund of the fee paid to NITK.

Name and Signature of the candidate with date

 Sponsorship (Deputation) Certificate /
No objection certificate
(For admission to M Tech (Research / Sponsored) / PhD Programme
during the academic year 2020-21)

The applicant (name).....................................................................................................has been a permanent staff of

this Institute/Organization from ……………….. and has …………….. years of experience
(teaching/R&D/industry).

(a) Sponsorship/(Deputation) certificate:

He/She is sponsored (deputed) with full Salary, for full time study/research in National Institute of Technology
Karnataka, Surathkal.

(b) No Objection Certificate:

For PhD Programme – He / She is permitted to undergo Part-time study/research in National Institute of
Technology Karnataka, Surathkal while continuing regular employment in the Institute/Organization and the
candidate and his/her sponsorship (deputation)/ NOC will not be withdrawn before the completion of the
course/programme.

For M Tech (Sponsored / Research) Programme – He / She is sponsored (deputed) with full salary, for full time
study in National Institute of Technology Karnataka, Surathkal and the candidate and his/her sponsorship
(deputation)/ NOC will not be withdrawn before the completion of the course/programme.

Official Seal

Station: Signature of the Employer

Date : Name:

Designation:

(Note: Sponsorship certificate should be submitted in the same format as indicated in this application form
duly signed by the Employer/ Sponsoring Institute Head and seal.)
 DISABILITY CERTIFICATE FORMAT - II

{In cases of amputation or complete permanent paralysis of limbs and in cases of blindness}

(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

No. - Date - / /

Signature/LTI/RTI of the Candidate Passport size

photograph
of the
candidate

This is to certify that I have carefully examined Shri/Smt./Kum. ,

son/wife/daughter of Shri Date of Birth / /

[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

1. he/she is a case of (Please tick as applicable):

a. locomotor disability
b. blindness
2. The diagnosis in his/hercase is .
3. 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).
4. The applicant has submitted the following document as proof of residence:-
Nature of Document Date of Issue Details of authority issuing the certificate

Official Seal:
[Authorized Signatory of notified Medical Authority] Name:
 DISABILITY CERTIFICATE FORMAT - III

{In cases of multiple disabilities}

(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

No. - Date - / /

Signature/LTI/RTI of the Candidate Passport size

photograph
of the
candidate

This is to certify that I have carefully examined Shri/Smt./Kum. ,

son/wife/daughter of Shri Date of Birth / /

[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

1. He/she is a Case of Multiple Disability. 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 tablebelow:
Permanent physical
Affected Part
S. No. Disability Diagnosis impairment/mental disability
of Body
(in %)

1 Locomotor disability @

2 Low vision #

3 Blindness Both Eyes

4 Hearing impairment £

5 Mental retardation X

6 Mental-illness X

Contd.
2. In the light of the above, his/her overall permanent physical impairment as per guidelines (to be
specified), is as follows:

In figures: %

In words: percent

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

4. 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

5. The applicant has submitted the following document as proof of residence:

Nature of Document Date of Issue Details of authority issuing the certificate

6. Signature and seal of the Medical Authority:

Name and Seal of Member Name of Seal of Member Name and Seal of the Chairperson
 DISABILITY CERTIFICATE FORMAT - IV

{In cases of any other case not covered in Format – II & III}

(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

No. - Date - / /

Signature/LTI/RTI of the Candidate

Passport size
photograph
of the
candidate

This is to certify that I have carefully examined Shri/Smt./Kum. ,

son/wife/daughter of Shri Date of Birth / /

[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

1. He/she is a Case of Multiple Disability. 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 tablebelow:
Permanent physical
Affected Part
S. No. Disability Diagnosis impairment/mental disability
of Body
(in %)

1 Locomotor disability @

2 Low vision #

3 Blindness Both Eyes

4 Hearing impairment £

5 Mental retardation X

6 Mental-illness X

Contd.
 2. In the light of the above, his/her overall permanent physical impairment as per guidelines (to be
specified), is as follows:

In figures: %

In words: percent

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

4. 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

5. The applicant has submitted the following document as proof of residence:

Nature of Document Date of Issue Details of authority issuing the certificate

Official Seal:

[Authorized Signatory of notified Medical Authority*]

Name:

* In case this certificate is issued by a medical authority who is not a government servant, it shall be valid only if
countersigned by the Chief Medical Officer of the District. Note: The principal rules were published in the Gazette
of India vide notification number S.O. 908(E), dated the 31st December, 1996.

Countersigned

Official Seal:
[CMO/Medical Superintendent/Head of Govt. Hospital]

Name:

^ Countersignature and seal of the CMO/Medical Superintendent/Head of Government Hospital is essential in

case the certificate is issued by a medical authority who is not a government servant.
 Format of Undertaking for PwD Candidates
.

I, __________________________________________ ____________ (Name of candidate)

Application ID. __________________________,
S/D/O_______________________________________ resident of ______________________
________________________ do hereby solemnly affirm and state as follows:

1. That, I am reporting online for the PhD 2020 Admission at NITK Surathkal.
2. That, I know that after online reporting, document verification will be done Online by the
official of the Institute based on documents uploaded by me and based on the online document
verification, a provisional admission letter will be issued to me by NITK Surathkal.
3. That, I know that physical examination is required to judge the percentage of disability, which
is not being done during Online Document Verification.
4. That, my physical examination will be done by the Medical Board of the Institute at the time
of physical reporting at the Institute.
5. That, at the time of physical reporting, if the Medical Board at the Institute finds that percentage
of my disability is below the required level, my admission will be cancelled and I will not have
any claim on my admission at NITK Surathkal.
6. That, if my seat is cancelled at the time of physical reporting, the refund, if any, will be dealt
as per Refund Rules of the Institute.

Deponent
Verification
I above named Deponent do hereby abide by the above Undertaking and verify on oath that the
contents of this Undertaking are true and correct to the best of my knowledge and belief and nothing
has been concealed therein and no part of it is false.

Deponent

Place: ___________

Date: ___________
 CERTIFICATE OF MEDICAL FITNESS
[To be obtained only from Gazetted Government Medical Officer / Medical Officer of a Government
Undertaking. (Please note that Medical Certificate issued by Private Practitioners will not be accepted) ]

Name (In Block Letters) ........................................................................................................................

Parent / Guardian Name ........................................................................................................................

Sex Male / Female Blood Group (Optional) ....................................

Height ...............................cm Weight .............................kg
Chest: Exp...........................cm Insp.. ...............................cm
Heart .................................. Lungs ............................
Vision ................................ Hearing .........................
Hernia / Hydrocele / Varicocele/Piles, etc: ...........................................................................................

Any Other Disease Diagnosed in the Past: ............................................................................................

Allergies, if any ......................................................................................................................................

Personal Marks of Identification:

1.
2.

I do hereby certify that I have examined Sri/Kum/Smt........................................................................,

A candidatefor .............................................................................and whose signature is given below
and that I could not notice that he/she has any disease, constitutional affection, bodily infirmity or
mental unsoundness.His/Her age according to his/her statement is .......................................................
year and by appearance about ........................... years.

Signature of the Candidate

Place ........................................... Signature:of the Medical Officer

Date ........................................... Name: _________________________________
Office Seal Designation: _______________________________
Registration No. ____________________________