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Department of Social Justice & Empowerment and Minorities/ Form for BC/OBC Caste Certificate / /
For Official Use Only/ Application Number / : Date of Application / Name of Block & Tehsil/ /
Part – 1 Beneficiary's Details 1. Fields marked with asterisk (*) are mandatory 2. Fill the details under this section in English & Punjabi
Part – 2 Service Details /
Application Details / 1. Mode of Delivery of Service/ Sewa Kendra / By Post / 2. Caste / *
3. Category/ * OBC BC
4. Religion/ * Christian Hindu Muslim Sikh Others
5. Verification Certificate Number /
6. Issue Date /
7. Issued To /
Details of Person Filling the Application Form /
Self-Attested
2. Address /
3. Relation with Beneficiary /
Personal Data of Beneficiary /
1. Beneficiary Name/ *
2. Father's Name/ *
3. Mother's Name/ *
4. Date of Birth / * Place of Birth/
5. Gender/ * Male Female Transgender
6. Marital Status/ * Married Unmarried Divorced Separated Widowed
7. Contact Phone Number/ *
8. Email ID/
9. Region/* Rural Urban
10. Permanent Address/ *
11. PIN Code/ * 12.Tehsil / Sub –Tehsil/ *
13. District/ * 14. State/ *
15. Town/City Name (in case or Urban region only)/ / ( ) *
16. Village Name (In case of Rural Region only)/ ( ) *
Correspondence address same as permanent address
16. Address of Correspondence/ *
17. PIN Code/ * 18. Tehsil / Sub –Tehsil/ *
19. District / * 20. State/ *
21. Town/City Name (in case or Urban Region only/ / ( ) *
22. Village Name (In case of Rural Region only)/ ( ) *
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8. Designation of issuing person/
9. Aadhar Number/ .
10. Aadhar enrollment number (If Aadhar not issued)/ ( )
11. Voter ID Card Number/
12. Application processing office/ *
Information regarding Parents Employed in Government Service / Father Mother
12. Class of Service /
13. Scale of Pay /
Information regarding Parents Employed in Private Service/ Father Mother
14. Name of the Organization/
15. Designation /
16.. Remuneration/
Agriculture land holding owned by whole family including Mother and Father /
17. Total Land Holding /
18.. Location /
19. Percentage of the total irrigated land/ ?
Vacant land or building in urban areas /
20. Property Details / Self-Occupied Rented
21. Use to which it is put /
22. Location /
23. Area of the Property /
24. Type of Property / Commercial Residential
Income/Wealth /
25. Annual Family Income from all sources/ *
26. Whether Income Tax payer/ * Yes No
Part -3 List of Required Documents. Please tick (√) the document attached
Name of Documents / Whether Mandatory / Optional
1. Copy of Residence Proof / Mandatory
2. Copy of Verification Leaf / Optional
3. Copy of Proof of Age / Mandatory
4. Copy of ID Proof / Mandatory
5. Copy of Self Declaration’s form / - Mandatory
/Declaration:-
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I Solemnly declare that the information provided as above and in attached documents is correct as per my belief
and no information has been hidden in this. I am aware of the fact that if any of the information provided by me is proved
incorrect/wrong then I can be punished in the court of law as per the provisions in the relevant Acts/rules/notifications and
depending upon this wrong information, all the benefits provided by government to me shall also be stopped immediately.
I submit my aadhar number voluntarily and give my consent to use my aadhar details to authenticate me from
UIDAI and link the aadhar number to my customer profile and certificates/documents issued to me by Government of
Punjab.
Note: In case of Minor, one of Family member (Father/Mother/Brother/Sister/Grandfather/Grandmother) needs to declare
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: ………………………………... ....................................................... /
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1. ………………………….. / /
2. : __________________:/- |
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:- __________________________

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