Annexure-III

Undertaking by Applicant

I, (Full name of applicant)___________________________________, hereby solemnly declare that I

obtained admission into direct Ph.D. program at (Name of Institute/University)______

_______________________________________________________ in year (Year of admission) ____________ after

receiving my B.E./B. Tech. degree and I successfully completed the course-work for Ph.D.

program with__________credits /grades. I further declare that I have not received

M.E./M. Tech. or any other P.G. degree separately after the B.E./B. Tech. degree.

Place:

Date: Signature of the Applicant

Name and Full Address as per Application

 Annexure-IV[A]

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 Shri/Shrimati/Kumari son/daughter of

of village/town in
District/Division in the State/Union Territory belongs to
the community which is recognized as a backward class under:
@Government of India, Ministry of Welfare Resolution No. 12011/68/93-BCC (C) dated 10th September, 1993 published in the Gazette of
India Extraordinary Part-I, Section-1, No. 186 dated 13th September, 1993.
@Government of India, Ministry of Welfare Resolution No. 12011/9/94-BCC dated 19- 10-94, published in the Gazette of India
Extraordinary Part-I, Section-1, No. 163 dated 20-10-1994.
@Government of India, Ministry of Welfare Resolution No. 12011/7/95-BCC dated 24-5- 95, published in the Gazette of India
Extraordinary Part-I, Section-1, No. 88 dated 25-5- 1995.
@Government of India, Ministry of Welfare Resolution No. 12011/96/94-BCC dated 9th March, 1996 published in the Gazette of India
Extraordinary Part-I, Section-1, No. 60 dated 11th March, 1996.
@Government of India, Ministry of Welfare Resolution No. 12011/44/96-BCC dated 6th December, 1996 published in the Gazette of
India Extraordinary Part-I, Section-1, No. 210 dated 11th December, 1996.
@Government of India, Ministry of Welfare Resolution No. 12011/99/94-BCC dated 11th December, 1997 published in the Gazette of
India Extraordinary Part-I, Section-1, No. 236 dated 12th December, 1997.
@Government of India, Ministry of Welfare Resolution No. 12011/13/97-BCC dated 3rd December, 1997 published in the Gazette of
India Extraordinary Part-I, Section-1, No. 239 dated 17th December, 1997.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/68/98-BCC dated the 27th October, 1999
published in the Gazette of India Extraordinary Part-I, Section-1, No. 241 dated the 27th October, 1999.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/88/98-BCC dated 6th December, 1999
published in the Gazette of India Extraordinary Part-I, Section-1, No. 270 dated 6th December, 1999.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/36/99-BCC dated 4th April, 2000 published
in the Gazette of India Extraordinary Part-I, Section-1, No. 71 dated 4th April, 2000.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/44/99-BCC dated the 21st September, 2000
published in the Gazette of India Extraordinary Part-I, Section-1, No. 210 dated the 21st September, 2000.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12015/9/2000-BCC dated 6th September, 2001
published in the Gazette of India Extraordinary Part-I, Section-1, No. 246 dated 6th September, 2001.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/1/2001-BCC dated 19th June, 2003
published in the Gazette of India Extraordinary Part-I, Section, 1 No. 151 dated 20th June, 2003.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/4/2002-BCC dated 13th January, 2004
published in the Gazette of India Extraordinary, Part-I Section-1, No. 9 dated 13th January, 2004.
@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/14/2004-BCC dated 12th March, 2007
published in the Gazette of India Extraordinary, Part-I, Section-1, No. 67 dated 12th March, 2007.

Shri/Shrimati/Kumari and/or his/her family ordinarily reside(s) in

village/town of District/Division of the State/Union
Territory of . 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.36012/22/93-Estt.(SCT) dated 8.9.1993, O.M. No.
36033/3/2004-Estt. (Res.) dated 9 thMarch, 2004 and O.M. No. 36033/3/2004- Estt. (Res.) dated
14thOctober, 2008.

Signature
Date: Place:
Designation
Official Seal
NOTE: The term “Ordinarily” used here will have the same meaning as in Section 20 of the Representation of the
People Act, 1950.

List of authorities empowered to issue OBC Certificate:

(i) District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner/Deputy

Collector/1st Class Stipendiary Magistrate/* Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant
Commissioner. (*not below of the rank of 1st Class Stipendiary Magistrate).
(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.
(iii) Revenue Officers not below the rank of Tehsildar.
(iv) Sub Divisional Officer of the area where the candidate and/or his/her family normally resides.
(v) Administrator/Secretary to Administrator/Development Officer(Lakshadweep).
 Annexure-IV[B]

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.
 Annexure-IV[C]

THE FORM OF CERTIFICATE TO BE PRODUCED BY PHYSICALLY HANDICAPPED

CANDIDATES APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF
INDIA.

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL

Certificate No. Date:

DISABILITY CERTIFICATE

Recent Photograph of
the candidate showing
the disability duly
attested by the
Chairperson of the
Medical Board.

This is certified that Shri/Smt./Kum. son/wife/daughter

of Shri age sex identification mark(s)

is suffering from permanent disability of following category:

A. Locomotor or Cerebral Palsy:

(i) BL – Both legs affected but not arms
(ii) BA –Both arms affected (a) Impaired reach
(b) Weakness of grip
(iii) BLA – Both legs and both arms affected
(iv) OL – One leg affected (right or left) (a) Impaired reach
(b) Weakness of grip
(c) Ataxic
(v) OA – One arm affected (a) Impaired reach
(b) Weakness of grip
(c) Ataxic
(vi) BH – Stiff back and hips (cannot sit or stoop)
(vii) MW – Muscular weakness and limited physical endurance

B. Blindness or Low Vision:

(i) B – Blind
(ii) PB – Partially blind

C. Hearing impairment:
(i) D – Deaf
(ii) PD – Partially deaf

(Delete the category whichever is not applicable)

This condition is progressive/non-progressive/likely to improve/not likely to improve. Re-assessment ofthiscaseis

notrecommended/isrecommendedafteraperiodof years months.
Percentage of disability in his/her case is percent.
Shri/Smt./Kum. meets the following physical requirements for
discharge of his/her duties:

(i) F–Can perform work by manipulating with fingers. Yes/No

(ii) PP–Can perform work by pulling and pushing. Yes/No
(iii) L–Can perform work by lifting. Yes/No
(iv) KC–Can perform work by kneeling and crouching. Yes/No
(v) B–Can perform work by bending. Yes/No
(vi) S–Can perform work by Siting. Yes/No
(vii) ST–Can perform work by standing. Yes/No
(viii) W–Can perform work by walking. Yes/No
(ix) SE–Can perform work by seeing. Yes/No
(x) H–Can perform work by hearing/speaking. Yes/No
(xi) RW–Can perform work by reading and writing. Yes/No

(Dr. ) (Dr. ) (Dr. )

Member Member Member
Medical Board Medical Board Medical Board

Countersigned by the Medical

Superintendent/CMO/Head of Hospital
(With seal)

* Strike out whichever is not applicable.

Annexure-IV[D]
 Annexure-V

Endorsement by the Present Employer

(on letterhead)

Forwarded to SARDAR VALLABHBHAI NATIONAL INSTITUTE OF

TECHNOLOGY, SURAT, GUJARAT, PIN: 395007

The applicant Dr./Mr./Mrs/Ms. …………………………………………………………, who

has submitted this application for the post of ………………………………………………..

in the Sardar Vallabhbhai National Institute of Technology, Surat, has been working in this

organization namely……………………………………………………………………….

as …………………………………(name of the post), in a temporary/ contract/ permanent

capacity with effect from ………………… in the Scale of Pay/ Pay Band of

Rs………………………. He/She is drawing a basic pay of Rs. …………….. His/her next

increment is due on …………………………………..

Also, on his/her selection, he/she will be relieved from the present position of …………….
…………………………

Further, it is certified that no disciplinary/vigilance case has ever been held or contemplated
or is pending against the said applicant. There is no objection for his/ her application being
considered by the Sardar Vallabhbhai National Institute of Technology, Surat, Gujarat.

Date

Place

Signature of the forwarding Authority

Name
Designation
Seal