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Form of
Application for issue of Community, Nativity and Date of Birth
Certificate relating to Scheduled
CASTE/ BACKWARD
CLASS under Section 3(1) of the Act 16 of 1993
(Information
to be furnished by the applicant himself supported by the
documentary evidence) |
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| To |
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The Mandal
Revenue Officer,
Shaikpet Mandal
Hyderabad
District |
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| Sir, |
I am in need of Scheduled Caste/Backward Class Community certificate
for me / for my son/daughter for which the
details are give below |
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| 1. Name of the applicant
(in block letter) |
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| 2.
Sex of the applicant |
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3.
a) Father Name
b) Mother Name |
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| 4.
Present postal address |
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5.
Place of permanent residence of the Certificate Seeker /
is father / paternal Grand father as on the date of first
Notification declaring the community as Scheduled Tribe,
to which the certificate Seeker claims to belong |
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6.
Age, date of birth and place of birth
(If date is known
approximate year of birth) |
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7.
Place of ordinary residence (documents relating to
house/land or other immovable property or Birth
registration
certificate or ration card or school records
may be furnished) |
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8.
If the applicant has been issued a community certificate
in the past by any authority, a copy of such certificate
should be furnished |
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9. Community for which certificate is claimed
(Including sub-tribe or sub-group) |
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10.
a) Community of the father
(Including sub-tribe or sub-group)
b) Community of the Mother
(Including sub-tribe or sub-group) |
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11.
Whether the applicant is
a) a natural born son or daughter of his/her parents
(OR)
b) adopted son/daughter of his/her parents |
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DECLARATION |
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I/We
declare that the information furnished by me/us in the application
is true and Correct, and the documents appended
thereto are
genuine and
the contents of the documents are true and correct and
that if these are found to be untrue and
incorrect I/We shall be
liable for prosecution for
furnishing false and incorrect
information / documents under section 10
of the Act No. 16 of 1993. |
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| STATION |
Signature of
the
Applicant |
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| DATED |
Signature of
the Parent/Guardian |