"Application Form for a Certificate for Eligibility for Reservation of Jobs for Other Backward Classes in Civil Posts and Services" - Goa, India

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Page 1

ANNEXURE B

APPLICATION FORM FOR A CERTIFICATE

FOR ELIGIBILITY FOR

RESERVATION OF JOBS FOR OTHER BACKWARD CLASSES IN CIVIL POSTS

AND SERVICES GOVERNMENT OF INDIA

This form however, shall be used only as a Additional items, if necessary, may be

incorporated to suit to the local situation in the form.

To,

Deputy Collector of SDO

_________–Goa.

I, request that a certificate in respect of reservations for other backward classes posts and

services under Government of India be granted to me.

I give below the necessary particulars:

1. Full name of the Applicants

(In Block Letters)

2. Date of Birth

3. Complete Residence Address

(a) Present

(b) Permanent

4. Religion

5. Caste

6. Sub-Caste

7. Occupation

8. Serial Number of the Central

List of OBC’s

9. Name of Father

10. Name of Mother

11. Name of Husband

12. Status of Parent (S) Husband

Father

Mother

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Page 1

ANNEXURE B

APPLICATION FORM FOR A CERTIFICATE

FOR ELIGIBILITY FOR

RESERVATION OF JOBS FOR OTHER BACKWARD CLASSES IN CIVIL POSTS

AND SERVICES GOVERNMENT OF INDIA

This form however, shall be used only as a Additional items, if necessary, may be

incorporated to suit to the local situation in the form.

To,

Deputy Collector of SDO

_________–Goa.

I, request that a certificate in respect of reservations for other backward classes posts and

services under Government of India be granted to me.

I give below the necessary particulars:

1. Full name of the Applicants

(In Block Letters)

2. Date of Birth

3. Complete Residence Address

(a) Present

(b) Permanent

4. Religion

5. Caste

6. Sub-Caste

7. Occupation

8. Serial Number of the Central

List of OBC’s

9. Name of Father

10. Name of Mother

11. Name of Husband

12. Status of Parent (S) Husband

Father

Mother

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Page 2

(A) Constructional Post

( I ) Designation

(B) Government Service

(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

UNICEP, WHO

(i)

Name of the organization

(ii)

Designation of Services

(iii)

Periods of Services

(Indicate date from .____________________to _________________ )

III. Death / Permanent Incapacitation (Omit if not applicable)

(i)

Date of Death /permanent

Incapacitation putting an officer out of services

(ii)

Details of permanent incapacitation.

(i)

Name of the Organization

(ii)

Designation

(iii)

Date of Appointment to the post

( D ) Armed forces including pare-military Forces

(This will not include person holding civil post)

(i)

Designation

(ii)

Scale of pay

( E ) Professional Class (other than these covered in item Nos B & C ) and those

engaged in trade, Business and Industry

(i)

Occupation / Profession

( F ) Property owner

(A)

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)

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Page 3

(iv )

Percentage of irrigated land holding to statutory ceiling

limit under state land ceiling laws

( v )

If land holding is both irrigated/ unirrigated total

irrigated land holding on the basis of conversion

formula in State land Ceiling Law

( vi)

Percentage of total irrigated land holding to statutory ceiling as

per (iv)

( B ) Plantation :

(i)

Crops/ Fruits

(ii)

Location

(iii)

Area of Plantation

( C ) Vacant Land and /or building in Urban agglomeration

( a ) Location of Property

( b ) Details of Property

( c ) Use to which it 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 last three year to be finished)

(iii)

Wheather covered in Wealth Tax Act (Yes/No)

(if so furnish details)

13. Any other remarks

14. 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 OBC’s and eligible to be

considered for posts reserved for OBC’s. In any event of my information being

found false or incorrect, or ineligibility being detected before or after the selection.

I undersigned that my candidate/ appointment it liable to be cancelled and I shall

be liable to such further action a may be provided under the law and or Rules.

Signature of the Candidate

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