"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
Downloaded From: www.collectornorth.goa.gov.in
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
Downloaded From: www.collectornorth.goa.gov.in
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.
(C) Employment in public Sector Undertaking etc.
(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)
Downloaded From: www.collectornorth.goa.gov.in
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
Downloaded From: www.collectornorth.goa.gov.in
Certificate of Eligibility Form Certificate Template

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