Application form for Certificate for Eligibility for Reservation for

Other Backward Classes

(This form however should be used as a model additional items, if necessary, may be
incorporate to suit to the local situation in the form)

To
The Tehsildar
Jagadhri (Haryana)

Sir,

I request that a certificate in respect of reservation of other Backward
Classes in Civil and services under Govt. of India 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. Occupation :-
8. Serial Number of the caste in
Central List of OBCs :-
9. Name of Father :-
10. Name of Mother :-
11. Name of Husband :-
12. Status of Husband/Parents (s) :-
Father Mother Husband



a) Constitunal Posts
b) Designational
c) Governmental Services.
i) Service (Central/State)
ii) Designation
iii) Scale of pay including
Classification, if any
iv) Date of appointment to
the post
v) Age at the time of promotion
to class I post (if Applicable) :-
II. Employement in International
Organisation eg. UN, UNICEF,
UNO.










i) Name of Organisation :-
ii) Designation :-
iii) Period of service
(indicate date from _______________________to ____________________
i) Death/Incapacitation (Omit if not applicable)
Putting officer out of service :-
ii) Details of permanent incapacitation.
C. Department in Public Sector undertaking etc.
i) Name of the Organisation
ii) iv) Date of appointment to the post:-
D. Arms forces including Para-Military Forces.
(This will not include persons holding civil posts)
i) Designation
ii) Scale of Pay
E. Professional include persons holding civil covered
In NOS.S & Sand those engaged in Trade,
Business and Industry :-
i) Orgn. Profession :-
F. Property owners :-
I. Agricultural Land Holding Owner 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 ceiling limit under state
land ceiling laws.
v) If any lying is both irrigated/
unirrigated total land
holding on the state land ceiling law.
vi) Percentage in ceiling limit as per (iv)
E)-II- Plantation
i) Crops/fruit :-
ii) Location
iii) Area of plantation
F)-III- Vacant land/or building in urban areas
Or urban applemention.
i) Location of property :-
ii) Details of property :-
iii) Use of which it is put :-
G) Income/wealth
i) Annual family income from all sources
(Excluding salary & income from agricultural
land.)
ii) Whether Tax Pay (Yes/No)
(If yes a copy of the last three years return
be furnished).
iii) Whether covered in wealth Tax Act. (Yes/No)
H) Any other remarks :-







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