FORM OF CERTIFICATE TO BE PRODUCED BY BACKWARD CLASSES FOR CLAIMING RESERVATION

AND / OR AGE CONCESSION.

Serial No.

District Code:
Mandal Code:
Village Code:

Certificate No.
1) This is to certify that Sri/Smt/Kum________________________________ Son/Daughter of Sri
_________________________________________

of

Village/Town_____________________Mandal________________ District _________________ of the

state of Andhra Pradesh belongs to ________ Community which is recognized as B.c. subgroup
___________
2) It is certified that Sri/Smt/Kum __________________________ is a native of ___________________
Village/Town ____________________ Mandal ____________________ District of Andhra Pradesh.
3) It is certified that the place of birth of Sri/Smt/Kum _________________ is ____________________
Village/Town _____________________ Mandal ________________ District of Andhra Pradesh.
4) It

is

certified

that

the

place

of

birth

of

Sri/Smt/Kum

_________________

is

___________________Village/Town_______________________ Mandal ________________ District

of Andhra Pradesh.
5) It is certified that Sri/Smt/Kum ___________________________ does not belong to the section of
Creamy layer as per G.O. Ms. No. 3, Backward Classes Welfare (C2) Department dated 04-04-2006
of the Government of Andhra Pradesh.
(* Strike out if it is not applicable)

Signature:
Date:
Name in Capital Letters:
Designation:
(Seal)

This is for information of the Candidate