APPLICATION FORM FOR A CERTIFICATE FOR ELIGIBILITY FOR RESERVATIONOF JOBS FOR OTHER BACKWARD CLASSES IN CIVIL POSTS AND SERVICES

UNDER GOVERNMENT OF DELHI

No.To,

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Sir,

I request that a certificate in respect of reservation for other Backward Classes in CivilPosts and Services under Government of Delhi be granted to me.

I give below the necessary particulars:-

1. Full Name of the applicant(in BLOCK letters) ................................ ................................ ................................ .

2. Date of Birth ................................ ................................ ................................ ...........

3. Complete Residential Address

(a) Present................................ ................................ ................................ .............

(b) Permanent................................ ................................ ................................ ........

4. Religion................................ ................................ ................................ ..................

5. Caste................................ ................................ ................................ .......................

6. Sub-Caste ................................ ................................ ................................ ...............

7. Occupational Group................................ ................................ ................................

8. Serial Number of the Caste in theCentral List of OBCs................................ ................................ ...............................

9. Name of Father and address ................................ ................................ ....................

................................ ................................ ................................ ...............................

10. Name of Mother................................ ................................ ................................ ......

11. Name of Husband ................................ ................................ ................................ ...

12. Status of Parent(s)/Husband ................................ ................................ ....................

Affix your photohere

(Passport size)

(A) Constitutional PostsFather Mother Husband

I. Designation ..........................................................................................................

(B) Government Service

(i) Service (Central/State)...........................................................................................

(ii) Designation ...........................................................................................................

(iii) Scale of Pay, Includingclassification, 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 Organisation e.g. UN, UNICEF, WHO:

(i) Name of Organisation......................................................................................

(ii) Designation .....................................................................................................

(iii) Period of Service ............................................................................................(indicate date from … … … ..… … to … … … … ..… … )

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

(i) Date of death/Permanent incapacitationputting an officer out of service .......................................................................

(ii) Details of Permanent Incapacitation.................................................................

(C) Employment in Public Sector Undertakings etc.

(i) Name of Organisation ...................................................................................

(ii) Designation...................................................................................................

(iii) Date of appointment to the Post ....................................................................

(D) Armed Forces including Para-military Forces(This will not include persons holding civil posts)

(i) Designation .....................................................................................................

(ii) Scale of Pay.....................................................................................................

(E) Professional class (other than those covered in item Nos. B &C)and those engaged in trade, Business and Industry

(i) Occupation/Profession .....................................................................................

(F) PROPERTY OWNERS

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) Unirrigated ...................................................................................................

(iv) Percentage of irrigated land holding to statutory ceilinglimit under State Land Ceiling Laws

(v) If land holding is both irrigated/unirrigated total irrigatedland holdings on the bases of conversion formula in StateLand Ceiling Law

(vi) Percentage of total irrigated land holding to statutoryceiling limit as per (iv)

II. Plantation

(i) Crops/Fruit .........................................................................................................

(ii) Location .............................................................................................................

(iii) Area of Plantation...............................................................................................

III. Vacant land and/or building in urban areas or urban agglomeration

(i) Location of Property...........................................................................................

(ii) Details of Property..............................................................................................

(iii) Use to which it is put ..........................................................................................

(G) Income/Wealth

(i) Annual family income from all sources (excluding salaries & income fromagricultural land)

(ii) Whether Tax Payer (if yes, a copy of the last three years Return be furnished)(Yes/No)

(iii) Whether covered in Wealth Tax Act (if so furnish details)(Yes/No)

To be certified byDistrict RevenueOfficer not lower thanthe rank of Tehsildar

13. Any other remarks

14. I certify that above said particulars are true to the best of my knowledge and beliefand that I do not belong to the Creamy Layer of OBCs and eligible to be considered for postsreserved for OBCs. In the event of any information being found false or incorrect, orineligibility being detected before or after the selection, I understand that mycandidature/appointment is liable to be cancelled and I shall be liable to such further action asmay be provided under the law and/or Rules.

Yours faithfully,

Place Date Signature of the candidate

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ACKNOWLEDGEMENT RECEIPT

No.

Received application form for issue of O.B.C. Certificate from Shri/Smt./Km.

… … … … … … … … … … … … … … … … … … .. S/o/D/o/W/o … … … … … … … … … … … … … .

R/o … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … ..…

… … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … … …

today on … … … … … … … … … … … … … … …

The applicant may contact S.D.M. (… … … … … … … … … … … … … … )

on … … … … … … .. for receipt of O.B.C. Certificate.

(Full Signature of Receiving Officer with Stamp)

ANNEXURE - 1

Supporting documents required along with the application forms:-

S.No. Column No. of application form Supporting documents required to beattached/information to be provided by applicant

1. 2 Date of Birth Birth Certificate

2. 3 Residential Address Copy of Ration Card or any other document such asidentity card issued by Election Office, Passport etc.

3. 7 Occupational Group Indicate If:(a) Student(b) Service(c) Business(d) Agriculture(e) Others (to be specified)

4. 12:1 & 2 Certificate to be obtained from the Head of Office

5. 12-3 (Death/Permanent Incapacitation) Death Certificate

Medical Certificate issued by the Board constitutedfor the purpose or Certificate from the Departmentregarding removal from Service on account ofPermanent incapacitation.

6. 12(F) (iv) (v) (vi) Certificate from an Officer not below the rank ofTehsildar.

7. 12(g) Affidavit to the effect that neither he/she nor his/herparents or any other member of his/her family is anIncome Tax Payee.

8. To specify Trade/Business/Industry, affidavit incase not exceeding the Income Tax limit and ifexceeding the income tax limit, income taxassessment orders for three preceding consecutiveyears.

ANNEXURE –2

LIST OF OBC CASTES FOR NATIONAL CAPITAL TERRITORY OF DELHI NOTIFIEDBY GOVERNMENT OF INDIA FOR THE POSTS RESERVED UNDER G.O.I.

1. Abbasi, Bhishti, Sakka 25. Jogi, Goswami, Nath, Yogi, Jugi, Gosain2. Agri, Kharwal, Kharol, Khariwal 26. Julaha (excluding those in SC’s), Ansari3. Ahir, Yadav, Gwala 27. Kachhi, Koeri, Murai, Murao, Maurya,4. Arain, Rayee, Kunjra Kushwaha, Shakya, Mahato5. Badhai, Barhai, Khait, Tarkhan, Jangra Brahmin, 28. Kasai, Qassab, Quraishi

Vishwakarma, Khati Panchal, Mathul Brahmin 29. Kasera, Tamera, Thathiar6. Badi 30. Khatgune7. Bairagi 31. Khatik (excluding those in SCs)8. Bairwa, Berwa 32. Kumhar, Prajapati9. Barai, Bari, Tamboli 33. Kurmi10. Bauria/Bawria (excluding those in SCs) 34. Lakhera, Manihar11. Bazigar, Nat, Kalandar (excluding those in SCs) 35. Lodhi, Lodha, Lodh, Maha Lodh12. Bharbhooja, Kanu 36. Luhar, Bhubhalia13. Bhat, Bhatra, Darpi, Ramiya 37. Machi, Machhera14. Bhatiara 38. Mali, Saini, Southia, Sagarwansi-Mali, Nayak15. Chak 39. Memar, Raj16. Chippi, Tonk Darzi, Idrishi(Momin), Chimba 40. Mina/Meena17. Dakaut, Prade 41. Merasi, Mirasi18. Dhinwar, Jhinwar, Nishad, Kewat/Mallah 42. Mochi (excluding those in SCs)

(excluding those in SCs), Kashyap (Non Brahmin), 43. Nai, Hajjam, Nai (Sabita), Sain, SalmaniKahar 44. Nalband

19. Dhobi (excluding those in SCs) 45. Naqqal20. Dhunia, Pinjara, Kandera-Karan, Dhunnewala, 46. Pakhiwara

Naddati, Mansoori 47. Patwa21. Fakir 48. Pathar Chera, Sangtarash22. Gadaria, Gadheri, Gaddi, Garri, Pal, Bughel, 49. Rangrez

Dhangar, Nikhar, Kurba 50. Raya-Tanwar23. Ghasiara, Ghosi 51. Sunar24. Gujar, Gurjar 52. Rai-Sikh