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ANNEXURE -'A'

(Format of certilicate to tre produced by a Appticants belonging to Scheduled castes or scheduled rribes in support of

Claim)

ThisistocertifythatShri/Smt./.KumuSon/Daughter*ofof village -/ t"*"-

tof state / union Territoryx

---belongs to the ---

caste / Tribe* which is t"rognir"a as a scheduled caste / Scheduled Tribex under :

a

a

a

The constitr-rtion (scheduled caste) i (Scheduled Tribes) order, 1950.

The Constihrtion (Scheduled Caste) (Union Territories) Order' 1951' ,

The Constitr-rtion (Scheduled Tribes) (Union Tenitories) order, 195 1(as amended bythe Scheduled Caste

and Scheduled T'bes Lists Modification), order, 19i6. The Born5ay Re-Organisation Act 1960, The

Punjab Re-Organisatton Act, 1966, The State of Himachal Pradesh Act, 1970, The North Eastern Areas Re-

Organisation Act, !97 !,and the Scheduled Caste / Scheduled Tribes Order (Amendment) Act' 1976'

The constitution (Jammu and Kashmir) Scheduled caste / Scheduled Tribe order, 1956' iThe constitution (Andaman and Nicobar Islands) Scheduled Tribes order. 1959'

' The Constitution (Dadra and Nagar Haveli) Sclieduled Castes / Scheduled Tribes Order ' !962'

The Constitution (Pondichery) Scheduled Castes Order, i964'

The Constitution Scheduled Tnbes (Uttar Pradesh) Order' 1967'

The constitution (Goa, Daman and Diu) scheclulecl castes / scheduled Tribes order, 1968'

The Constitution (Nagaland) Scheduled Tribes Order,1970'

The constitution (sikkim) Scheduled caste I Scheduled Tribes order,19'78.

The constitution (Jammu and Kashmir) scheduled Tribes order, 1989.

The Constitution (SC) Orders (Amendment) Act, 1990'

a

a

a

a

a

a

)

TlreConstitution(ST)orders(Amendment)Act,ordinancel991'The Constitution (ST) Orders (Second Amendment) Act, 1991'

The Constitution (ST) Orders (Amendment) Ordinance, 1996'

ApplicationinthecaseofScheduledCaste/ScheduledTribePersonsState / Union Territory Administration'

who have migrated from One

This certificate is issued on the basis of Scheduled caste I Scheduled Tribe certificate issued to Shri /ofFather / Mother of Shri / SmL / Kum

of State / Union TerritorY

a

a

a

a

a

a

a

Smt / Krrm* latner / lvroul

\/illaoc / tmm in Dlstrict / Division*who belongs to the Caste / Tribex which is recognized as a

issued bY thes.h.d"l.d c^t" / Scheduled Tribe * in State / Union Territory

(Name of prescribed authority) vide their No' ---.___-.-3. Shri

town*State / Union TerritorY of

Union Territory of

Signature

Designatton

(with seal of office)

(*) please delete the words which are not applicable (*) Please quote specific presidenti4l offer (*)' Delete the

Paragraoh which is not applicable' (*)

please Note: The term *Ordinarily resides* used will have the same tneaning as in Section 20 of the Representation

of the PeoPle Act, L950'

List of Authorities empowered to issue caste / tribe certilicates : f

1. Disrrict Magistrate / Additional District Magistratc / collector / Deputy commissioner / Additional Deputy

com*rissione, / D;p"tft"|".t* I t" ctui, Stipendiary Magistrate / Sub Divisional Magistrate / Taluka

Magistrate / Executive Magistrate I Exlra Assistant Commissioner'

z. Chiif presidency MagistraL/adrlitional Chief Presidency Magistrate/Presidency Magistrate'

3 . Revenues Officers not below the rank of Tehsildtu'

4. Sub Divisional Oflicer of the area where the Applicants and / or his family normally resides'

dated

/ Smt. / Kum.* and or his / her* family ordinarily reside(s) in village I

of District / Division of State iPlace

?uWNs-e

ANNFXURE -,'B'

oBc GEBTIFICATE FqRMAT

This is to certify that Shri / Smt' / Kumari ------- son I

daughterof_____orvirrage/Town____--=inDistrict/Division in the state / Union Territory --nelongs to ffre community which is recognised as

a Backward class under the Government oi India, Ministry of social,Justice and

Empowerment's Resolution No' dated

Shri / Smt. / Kum.- and / or ,his i her family

ordinarily reside(s) in the ------------:--- Oi state / Union

Territory. This is atso io "Grt'tv ''.'at

f.elstre does not belong to pre persons / seciions (Creamy

layer) mentioned in."otu*n S 1ot tf,* Sth"Ouf" to the Givernment of lndia' Department of'

personnet & Training oM No. 36012/22.1g3-Estt(scT), dated 8.9'1993 and modified vide

Government of India, Department of personner and Training 0.M'No.360331112013-Estt' (Res)

dated 27.05.2A13 and 13.09'2017.'

Date :

DISTRICT MAGISTRATE /

DY. COMMISSIONER ETC' .

(Seal )

* The authority issuing the certificate may have to mention the details of

Resolution of Government of India, in which the caste of the candidate as oBc'

* As amended from time to time'

Note: The term ,,ordinarily,' used here will have the same meaning as in Section 20

of the Representation of the People Act' 1950'

Pqt" Pv - lD

Annexure C

wpeq qfteroi qfluf-qfMEDICAL FITNESS CERTIFICATE

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nPo.ee N* -ll'o

ANNEXURE _'D'

FORM OF MEDICAL CERTIFICATE FOR PERSONS WITH DISABILITIES (PWD)

NAME & ADDRESS OF THE INSTITUTE/IIOSPITALDISABILITY CERTIFICATE

Certificate No. Date

1. This is to certify that Smt, / Shri / Kum*Son / daughter of ShriFemale having identification marks as belolr'suflering from Pernanent disability of following category.

A. Loco motor or cerebral palsy :

(i) BL-Both legs affected but not arms.

(ii) BA-Both arms aflected : (a) Impaired reach,

(iii) Ol--one leg affected (right or left) : (a) Impaired reach,(c) Ataxic

meets the

age _, Male /is

(Paste here recentpassport size

colourphotograph ofthe

Applicants ofsize4cmx5cm

Signature ofApplicants

(b) Weakness of grip,

(b) Weakness of grip,

(iv) OA-One arm affected (right or left) : (a) Impaired reach, (b) Weakness of grip, (6) Ataxic

(v) BH-Stiff back and hips (cannot sit or stoop)

(vi) MW - Muscular weakness and limited physical endurance.

B. Blindness or Low Vision : (i) B-Blind, (ii) PB-Partially Blind,

C Hearing Impairment : (i) D-Deal (ii) PD- Partially Deaf

(Delete the category whichever is not applicable)2. This condition is progressive/non-progressive/likely to improve/not likely to improve. Re-assessment of this

case is not recommended/is recommended after a period of

-

year monthS.

3. Percentage ofdisability in his/her case is Pcraent.

following physical requirement for discharge of his,/her4. Smt./Shri.iKum*duties:

(i)

(iD

(iii)(iv)

(v,

(vi)

(vii)(viii)(ix)

(x.)

(xi)

F-can perform work by manipulating with fingers

PP-can perform work by pulling and pushing

L-can perform work by liftingKC-can perform work by kneeling and crouching

B-can perlbrm work by bending

S-can perlbrm work bv sitting

ST-can perform work by standing

W-can perform work by walking

SE-can perform work by seeing

H-can perform work by hearing / speaking

RW-can perform work by reading and writing

(Signature of Doctor)Name:Registration No.Member, Medical Board

Yes No

Yes No

Yes No

Yes No'

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

(Signature ofDoctor)Name:Registration No.Member/Chairperson, Medical

(Signaturc ofDoctor)Name:Registration No.Member, Medical BoardBoard

*Please delete the words which are not applicable

Place:Date : Counter signature of the Medicai

Superintendent/CMO/ Head of Hospital(with seal)

Note:

(i) accolding to the persons with Disabilities (Equal Opportunities, Protection of Rights and full participatibn) Rules, 1996

notihed on 31.12.1996 bythe Central Governmentin exercise of the powers conferredbysub-Section(l) and(2) of Section 73

of the Persons with Disabilities (Equal Opportunities, Protection of tughts and Full Parlicipation) Act. 1995 (1 0f 1996),

authorities to give disability Certificate will be a Medical Board duly constituted by the Central or the State Government. The

State Government may constitute a Medical Board consisting of at least three members out of whom at least one shail be a

specialist in the pafiicular field for assessing locomotors/ hearing and speech disability, mental retardation and leprosy cured as

the case may be.

(ii) The certilicate would be valid for a period of 5 years for those whose disability is temporary. For those who acquiled

porrnanent disability, the validity can be shown as permanent.

?onzN'e -\2

ical fitness for

Annexure E

Standa traininApprgnticeship Act L951

, -,.r+:,.,::<*+:'.ri;r*;i'r+*'5i.na1*,.,'i g!1'1.." :;'

-':r*--:r:ii;:!l'i:*ri-:!Fr;!l1.':'icii'i!*:s;**i!:i5'l''-:::i:!r:*;?:;*::1:1ji:=€qt}$s'iiti3{rj.j-+(1)Acandidate_shouldbefreeeviderrceof.anycontagiousorinfectiousdisease. He should not u, ,onrt*g,d"-ry *t dit"*t which is likely to be

aggravared by iervice- or. is 15rV i" tfra* ry* ""fit

for service or erdanger the

health of the pubiic, He should uiso b. free from evidence of nrberculosis in any

form' acttve or liealed'

(2) Height. Weight And Chest

Candidates should satisfy the following minirnum standards, nanely:. :'

HEIGHT: l3.l centimeters; Weigtrr:zs.+ Kilogram.; Chest expansion should

not be less than 3'8 centimeters ines'pective of size of chest:

Provrdethatwhereacarrdidatedoesirotsatisfythe-saidrninimumsrandards but is certified in writin!'fv u rtttOltal Officer not below the rank of

an Assrsranr Surgeon (Gazettedi, -io.

ue prrvsicar! fit for being engaged as an

apprentice in ;;;;it"iI .trade under the Apprentices 'Act'1961'

he may be

engag.O as an apprentice in that trade'

(3) EYES

Thereshouldbenoevidenceofany'morbid.".19]:."^"ofeithereyeofthelidsofeithereyewnicrrmaybeliabletoriskofagglavationofrecurrence.

Standa.rd of Visiotl

(A) Visual acr"rity: 'rCandidates havrng vision.in one eye shall eligible to undergo

appt.enticeslriptrairringex^ceptrnth"elollowingseventeentrades,namely:-(l)ElectrlcianAiicraft"..'rzlWatchandCiockMechanic(3) Drtt'er cum Fitter (4) SurveYor

(5) Process Cameraman (6) Sirdar

(7) tugger(Engg' & Chem' tndustry) iqi, ShorfirerlBlaster(Mines)

(g) Mate(Mines) 'F"---l',

irb) Mech' Radio & Radar Aircraft

(11) Ceramic Moduler (12) Ceramic Caster

(13) Ceramic i(iln Operator' (14) Ceramic Press Operator

(i 5) Ceramic Modeller ( l6) Ceramic Decoralor

(17) OPtical worker

1't APril 1993

P oa" NrY - t3

(b) Colour vision: Not required

(4) EARS

Hearing must be good in both ears and there should be no sign of suppurative

disease. No hearing aid shall be permitted.

(5) SKIN :

There should be no evidence of acute or chronic skin disease or chronic

ulceration. .

(6) SPEECH:

Speech should preferably be without impediment.

(7) ALIMENTARY SYSTEM:

1. Candidates should have sufficient number of natural teeth (in healthy state)

for mastication.

2. Spleen should not be palpably enlarged and there should be no evidence

of tenderness in the splenic area.

3. Liver should not be palpable or tender.

4. There should be no oral sepsis.

5. There should be no susar in the urine.

6. Candidates should not be suffering from haemorrhoids, fissures inand testis anal hemia or bubonocele or ischio-rectal abscess or hydrocele.

(8) CARDIO VASCULAR SYSTEM:

1. Blood pressure should not exceed 85 diastolic and 140 systolic.

2. Candidates with 1ow blood pressure (i.e. systolic below 100) should be

reiected.

3. There should be no sign of any cardiovascular disease.

(9) RESPIRATORY SYSTEM:

Candidates should be free from all diseases of respiratory system. There

should be no deformity of chest which may cause impediment to breathing.

?W r'fs -lt

(10) GENTTO URINARY SYSTEMThere should be no evidence of genito urinary disease or any abnormality.

(11) SKELETAL SYSTEM:

1. The function of all limbs should be within normal limits.

2. There should be no evidence of serious defqr.mity of the spinal column orof the extremities.

(r2) NERVOUS SYSTEM:

There should be no evidence of any disease of nervous system or of anymental disease.

(r3) GLANpULAR SYSTEM

There should be no evidence of tuberculosis or other disease of the llandularsystem including the endocrine glands.

pase notS

Annexure F

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