FORM FOR A CERTIFICATE FOR ELIGIBILITY RESERVATION FOR OBC/NT(A)/NT(B)

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Applicant's Name : *	--Select-- Shri Smt Ku Dr
	First Name	Middle Name	Last Name
Birth Date : *	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912
Residential Address (Present) : *
	Pin code :    Ward :
Residential Address (Permanent) : *
Mobile No :
Religion :
Caste :	--Select-- Nomadic Tribes (B) Other Backward Class Nomadic Tribe
Sub-Caste :	;
Occupational group :
Serial no of the caste in the state list of OBC :
Father's Name :	--Select-- Shri Smt Ku Dr
	First Name	Middle Name	Last Name
Mother's Name :	--Select-- Shri Smt Ku Dr
	First Name	Middle Name	Last Name
Parent's/husband's details :
(a) Constitutional post :
(b) Designation :
(A) Government Services/Other services :
(i) Service (Central/State/Other) :
(ii) Designation :
(iii) Scale of pay including :            Classification if any
(iv) Date of appointment to post :
(v) Age at the time of promotion :           To class/post (if Applicable)
II Employment in International :       Organisation e.g. UNICEF
(a) Name of the Organisation :
(b) Designation :
(c) Period of service indicate date from :
(B) Death Permanent incapacitation  :       (omit if not applicable)
(a) Date of Death / Permanent :            Incapacitation Putting an Officer of service.
(b) Details of permanent incapacitation :            To class/post (if Applicable)
(C) Employment in public sector  :       Undertaking Put organization/ Profession
(a) Name of the Organisation :
(b) Designation :
(c) Date of appointment of the post :
(D) Armed forces including para-Military  :       forces.(The Will not Include persons holding the Post)
(E) Professional Class (other than those) :
(F) Property :
(F) Agriculture Land holding owned : Mother, Father and minor Children
(a) Location :
(b) Size of holding :
(c) (a) Irrigated
(i) :
(ii) :
(iii) :
(b) Non- Irrigated                  (To be certified by District Statutory                   Revenue Officer not Lower than)
(iv) Percentage of irrigated land holding to :                           selling limit under state of Land Selling                           Lacs
(v) If land holding is not irrigated unirrigated  :                          total irrigated land holding on the basic of                          conversion formula in State Land Selling                          Law
(vi) Percentage of total Irrigated land holding :                          to Statutory Selling Hands as per (IV)
(H) II Plantation :
(i) Crops / Fruits :
(ii) Location :
(iii) Area of plantation :
(I) Vacant land and/or building and urban areas :
(i) Location of property :
(ii) Detail of property :
(iii) use to without input :
(J) Income / wealth :
(i) Annual frankly income excluding salary           and income from agricultural land :
(ii) Whether tax payer :	Yes No
(iii) Whether converted in wealth tax :	Yes No
(K) Any other remark :