Application Form For Scheduled Caste And Scheduled Tribe Certificate (Page 2 of 3) in pdf

F. Migration Details :

(If applicable)

47. Have you migrated from another state *:

Yes

(Fill up below details 48-56 only if you have selected “Yes” in Sl no.47 above)

48. Applicant filling for ST/SC Certificate based on whom : Father

Mother

49. State/UT *:_______________________ 50. District *:______________________________________

51. Village/Town *:____________________ 52. Locality *:______________________________________

53. Caste/Tribe *:________________________ 54. Certificate No. *:______________________________

55. Scheduled Tribe/Caste Issuing Authority *: _______________________________________________________

(dd/mm/yyyy)

Date of Issuance of Certificate *:

56.

G. Details of Adoptive Parents :

Same Parent’s Details as above

(If applicable)

57. Whether Adopted *:

Yes

(Fill up below details58-65 only if y ou have selected “Yes” in sl no 57 above)

58. Father’s Name *:______________________________________________________________________

59 . Mother’s Name *:_____________________________________________________________________

60. State *:__________________________ 61. District *:_______________________________________

62. Village/Town *:____________________ 63. Locality *:______________________________________

64. Caste/Tribe *:__________________________ 65. Religion *:_______________________________

H. Declaration:

This is to certify that the information furnished as above are true to the best of my knowledge and belief and the applicant would be liable

for prosecution if found otherwise.

Date:

Place:

Signature of the Applicant

1. All columns marked with * are mandatory fields and must be filled in

2. Please refer the checklist for documents to be enclosed along with application form

3. In case, the applicant is minor, EPIC of father/mother should be submitted

4. The Recommendi ng Officer should give due importance while certifying in the application form and they shall

be liable to any action deemed fit by the Government in case of false recommendation.

For Office Use:

Checks before accepting the application

All mandatory fields are filled in properly

Signature of applicant & date of submission is mentioned

Verified & Accepted by:

Date:

CSC/PFC Token No:

___________________________

Signature of Receiving Assistant with Date

Mandatory Enclosures for -Scheduled Caste/Scheduled Tribe Certificate :

1. Passport Size Colour photograph .

2. Birth Certificate/SSLC Admit Card

3. Any One of Residential Proof (Ration Card/ Land documents /EPIC/ Electricity Bill/Telephone Bill)/Any

Government Certificate

4. ST/SC Certificates of Parents, in case applicant is minor

5. If adopted, Adoption documents (Court order/Registered Adoption deed)

In case of Migration, ST/SC Certificate from the migrating state

pplicant

EPIC is Mandatory

Father’s /Mother’s /Guardian’s or A

Note :

All enclosures should be self

attested

Application Form For Scheduled Caste And Scheduled Tribe Certificate Page 2

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