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OBC Certificate Application Form IA

1. The document is an online application form for an Other Backward Class certificate submitted to the Sub-Divisional Officer/D.W.O. in Kolkata. 2. The applicant, Tushar Ali, is applying for an OBC-A certificate under the Muslim Penchi caste. He provides personal details like date of birth, address, family information. 3. Tushar states his nationality as Indian, religion as Islam, and includes details of a paternal uncle who holds an OBC certificate as well as information for two referees residing in his village.

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Sirajdulla sk
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216 views1 page

OBC Certificate Application Form IA

1. The document is an online application form for an Other Backward Class certificate submitted to the Sub-Divisional Officer/D.W.O. in Kolkata. 2. The applicant, Tushar Ali, is applying for an OBC-A certificate under the Muslim Penchi caste. He provides personal details like date of birth, address, family information. 3. Tushar states his nationality as Indian, religion as Islam, and includes details of a paternal uncle who holds an OBC certificate as well as information for two referees residing in his village.

Uploaded by

Sirajdulla sk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd

FORM IA

SEE RULE 7BB[I]


FORM OF ON LINE APPLICATION FOR OTHER BACKWORD CLASS
To
The Sub-Divisional Officer / D.W.O, Kolkata & Ex-Officio Joint Director, B.C.W,
Jangipur , Murshidabad.
Sir,
I do hereby apply for OBC Certificate in the following prescribed proforma, for which particulars are
given below. I hereby undertake that the information is correct to the best of my knowledge and belief and
if anything found contrary I would be liable for that.

Yours faithfully,
Date:
(Signature of applicant / gurdian in case of minor)
Application No : OBCWB07022023/9914 ( Block : Suti-II )
1. (a) Applying for : OBC-A (b) Name of caste : Muslim Penchi
2. Full Name of Applicant : TUSHAR ALI
: Father's Name
3. : HABIBUR RAHAMAN 5. Contact No. : 6294529704
4. (a) Date of Birth : 04/07/2003 6. Email Id. : [email protected]
(b) Place of Birth : 7. Adhar No. : XXXXXXXX1456
Village / Ward Police Station District State
NATUN KHANABARI SUTI MURSHIDABAD WEST BENGAL

8. Address since birth (a) Present address:


Para / House No. / Ward No. / G.P. Post Office Police Station District State PIN
Road / Village
HOQUESAHEB AURANGABAD DAHARPAR SUTI MURSHIDABAD WEST 742201
PARA BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
HOQUESAHEB PARA AURANGABAD DAHARPAR MURSHIDABAD WEST 742201
BENGAL

9. Nationality : INDIAN 10. Religion : Islam 11. Sex : Male


12. Whether any of the blood relations of the applicant posseses Caste Certificate? Yes
If answer to point no. 12 is 'Yes':
Name of cert. holder Relation with applicant Certificate No. Date of Issue Issuing authority
ATAUR RAHAMAN PATERNAL UNCLE 21152 13/01/2012 JANGIPUR

13. Details of two(2) referees:


Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
SIRAJDULLA SK VILL-NATUN KHANABARI P.O- TARIK ISLAM VILL-NATUN
DAHARPAR P.S-SUTI KHANABARI P.O-
14. Whether the applicant or his family migrated from other StateDAHARPAR
/ Country? P.S-SUTI No
If point no. 14 is 'Yes': Migration Certificate No. : Date of Issue :
Address of the applicant in his/her state of origin.
Village / Ward Police Station District State Country Year

Date: ( Signarure of applicant / gurdian in case of minor )

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