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11th Science
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Health Science Courses - Medical / Dental / Homeopathy / Unani / Ayurvedic / Physiotherapy / Nursing / etc
Management Courses - MBA / MCA etc
Higher Technical Educational Courses / Engineering / Pharmacy / HMCT / Architecture / etc Diploma
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Agriculture / Animal Husbandry / Dairy Development / Fisheries / Biotechnology / etc Diploma
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Technical Educational Courses After 10th Standard
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Page 2 of 30
Sr.No
1
2
3
4
5
6.
Compulsary Documents To Be Attached

Original Caste Certificate of the Applicant
Certified Copy of Caste Certificate of the Applicant
Original Affidavit (In Specimen Form 3 Rule - 4(1))
Original Affidavit (In Specimen Form 17 Rule - 14)
Certificate by the Principal of College (As per the last para of FORM-16, Rule14)
Attested Xerox copy of identity card issued by the college
Page 3 of 30

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Page 20 of 30
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Page 22 of 30
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Page 23 of 30
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Page 24 of 30
< Application Number D 1 8c) "

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@ 1 E-mail 1 .
From: cv@maharashtra.gov.in [mailto:cv@maharashtra.gov.in]
Sent: Thursday, December 13, 2012 1:14 PM
To: Shri Kumaji Mansaram Gaikwad
Subject: Caste Verification Application Status
Dr. Babasaheb Ambedkar Research And Training Institute, Caste Verification Information System
--------------------------------------------------------------------------------------------Dear Shri Kumaji Mansaram Gaikwad
Your Caste verification application 52120130101000027 saved successfully.
Regards,
Caste Validation Team,
Next Steps to be followed : 1. Please fill in details of documents to be submitted along with application using option "Document Details".
2. Please fill in Caste Verification details of your relatives using option "Relative Details".
3. Please take printout of Application Form using "Print Application Form" by "Confirm/Print Application" Option.
4. Please get the photocopy of your College Identification Card duly signed and attested by the Principal. This is to
be attached with the application form.
5. Please check the application form and details about documents and relatives. If required, the applicant can
make changes using Update Application, Document Details, and Relative Details options.
6. If satisfied with the application generated by the system, please confirm your application using option
"Confirm/Print Application".
Please note that once you confirm the application, you cant make any changes to the application.
7. Please take a printout of application slip by using Application Slip option. The application slip is
to be attached to the application form while submitting to college.
--------------------------------------------------------------------------------------------This is a system generated mail. Please do not reply to this email ID
Page 25 of 30
D F Login F LS 1 *4Y
:-
D / Compulsory Documents
-
Optional Documents .
Compulsory Documents
4

C
x
Certified Copy
Applicant
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/Print
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Certificate by the Principal of College (As per the

x
last para of FORM-16, Rule14)
of
Caste
Certificate
of
the
x
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Page 27 of 30
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Was Caste Validity Certificate Granted? :- Yes {
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successfully added in your relatives list, please ensure that you click on Save button to
Page 28 of 30
save your relative details ! DO / D .
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Relative details saved successfully ! DO / D .
:- 8c)1 O1 - Confirm/Print Application !"

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Page 29 of 30
* :-
Declaration :- Declaration " 1 <

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Done :- Done !" . 8c)1 1
Application is confirmed. Please take
a print of Application Slip and submit it along with application form and supporting documents
to your college
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Print Application Slip :- 8c)1 O1 - Application Slip !"

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Application Slip H Application Slip , /
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Page 30 of 30
CCVIS - Caste Certificate Verification Information System

Application Slip for - Case Type: For Students-Education
(Application Slip Generated by the website http://barti.maharashtra.gov.in)
(1) Application Number:
052120130101000027
Bar Code:
*052120130101000027*
(2) Applicant Details:

2.1 Name:
Shri Kumaji Mansaram Gaikwad
2.2 Gender: Male
2.3 Birth Date: 01/01/1992 2.4 Email Address:
2.6 Address of Correspondence:
avachatjb@hotmail.com
2.5 Mobile No: 9509509509
795 Ravivar Peth,

Laxmi Road,
Pune,
Taluka : Pune City, District : Pune, State : Maharashtra, Pin Code : 411030
2.7 Date of Application Confirmation:
31/01/2013
2.8 Permanent Registration Number allotted by the College:
3804
(3) Applicants Caste Certificate Details:

3.1 Caste Category:
Scheduled Caste
3.2 Caste:
Mahar (37)
3.3 Sub caste:
N.A
3.4 Caste Certificate Number: MAG/PH/SR/1462/2007

3.5 Caste Certificate Issued by:
3.6 District:
Sub Divisional Officer Pune Sub Division Pune
Pune
(4) Applicants College Details:

4.1 Name of College:
M.E.S. Abasaheb Garware College
4.2 Address of College:
Karve Road, Pune-4,

Deccan Gymkhana,Pune,
4.3 College Registration Number:

4.4 Studying in (11th or 12th Science):
PU/PN/A.S./009(1945)
11th Science
4.5 Division:
4.6 Roll No:
735
(5) Scrutiny Committee Details (To which the concerned college will submit the application.)
5.1 Name of Committee:
5.2 Address of Committee:
Divisional Caste Certificate Scrutiny Committee,

Pune Division Committee No.3, Pune
Students Hostel,Near Commezone, Yerwada, Pune, Taluka : Pune City, District : Pune, State : Maharashtra, Pin Code :
411006
(6) Document Details (Documents attached by the applicant)

Document Description
Year of document
Caste mentioned in the document
N.A
N.A
N.A
N.A
N.A
N.A
N.A
N.A
Certificate by the Principal of College (As per the last para of FORM-16, Rule14)
N.A
N.A
N.A
N.A
Primary School Leaving Certificate
01/06/1962
Mahar
Extract of Birth/Death Register(Village Register-14)
01/06/1930
Mahar
Caste Certificate issued by the Competent Authority
10/10/1960
Mahar
Note: 1. Application will not be accepted without the Original documents mentioned at Sr.No.1 to 3 above and the Xerox copy of the identity card
(attested by the Principal of College) mentioned at Sr. No.4 above.
2. The applicant should peruse section 8 of Maharashtra Act No. XXIII of 2001, and attach all necessary documents to prove his/her caste claim.
3. The above Act and Rules, 2012 thereunder are available on website http://barti.maharashtra.gov.in
Date of Submission of Application:
Acknowledgement by the College:
Signature of applicant:
Designed & Operationalised by

Dr. Babasaheb Ambedkar Research & Training Institute (BARTI), Pune 411001
Page 1 of 2
CCVIS - Caste Certificate Verification Information System

Application Slip for - Case Type: For Students-Education
(Application Slip Generated by the website http://barti.maharashtra.gov.in)
For further queries, the applicant may contact Toll Free number: 18002330444 helpline. (08.00 AM to 11.55 PM)
Designed & Operationalised by

Dr. Babasaheb Ambedkar Research & Training Institute (BARTI), Pune 411001
Page 2 of 2
EDUCATION
FORM-16
[ rule 14 ]
FOR STUDENTS
*052120130101000027*
Application Form for verification of Scheduled Caste / Scheduled Caste convert to Buddhism/De-Notified
Tribe (Vimukta Jati)/ Nomadic Tribe/Other Backward Class/Special Backward Category Certificate to be
submitted to Divisional Caste Certificate Scrutiny Committee.
To,
Member Secretary and Research Officer,
Divisional Caste Certificate Scrutiny Committee,
Pune Division Committee No.3, Pune,
Students Hostel,Near Commezone, Yerwada, Pune, Taluka : Pune City, District : Pune, State :
Maharashtra, Pin Code : 411006
Sub :-
Affix
Passport size
Colour
Photo
Verification of Scheduled Caste Caste Certificate.
Sir,
I, the undersigned Shri Kumaji Mansaram Gaikwad hereby request to verify my Caste Certificate of Scheduled
Caste Category. Following information and documents are submitted herewith in support of my caste claim :1.
(a) Full name of the Applicant (as mentioned in Caste Certificate)

Shri Kumaji Mansaram Gaikwad
Present Address
795 Ravivar Peth,
Laxmi Road,
Pune,
(b) Mobile No.
9509509509
(c) E-Mail
avachatjb@hotmail.com
(d) Institute/College
M.E.S. Abasaheb Garware College
Name :
Course Name :
11th Science
Applicant's Institute/College Division : A
Applicant's Institute/College Roll Number : 735
2.
Caste/Sub Caste claimed by applicant

Caste :Mahar (37), Sub Caste : NA
3.
(a) Applicant's Birth date : 01-01-1992

(b) Applicant's Birth place : Deulgaon Raja
4.
Full Name of Applicant's Father

Shri Mansaram Dagadu Gaikwad
(a) Fathers Date of Birth :
01/01/1952
Pune
(b) Fathers Birth Place :
Permanent Address (If father is not alive please mention full address of his last residence.)
795 Ravivar Peth,
Laxmi Road,
Pune,
1 Of 8
5.
Full Name of applicant's Grand Father (Father's Father)

Dagadu Gaiwad
(a) Grand Father's Date of Birth : 01/06/1930
(b) Grand Father's Birth Place :
6.
Latur
Present occupation/service of applicant's Father
Service
Address with telephone number

Ziila Parishad
Address :Zilla Parishad, Pune
Pune 411 001
Telephone No
7.
Father's Education
: BCom
8.
Inherited Profession of Family : Agriculture
9.
(a) Applicant's Mother Tongue
: Marathi
(b) Applicant's Regional Dialect
: Marathi
(c) Applicant's God/Goddess
(d) Five Surnames of applicant's Relative/persons from caste :

Gaikwad, Waghmare, Kambale, Gaikwad, Kambale
10.
Applicant's (a) Native Place (Address) :

Latur,
Latur,
Taluka : Latur, District : Latur, State : Maharashtra, Pin Code : 0
(b) If applicant has left Native place
Please specify when and who left the place and reason for leaving :
Year of leaving:N.A
Person who left the native place:Grandfather
Reason : Family Matter

(c) Since when applicant is residing at present address.
1940
(d) At present who is residing at native place. Please give address and Telephone No.
Person Name :
Telephone No :
Address :
(e) Whether applicant is holding house/land at native place?
11.
No
Name of the competent authority from whom caste certificate is obtained and Certificate No. and Date.
Competent Authority : Sub Divisional Officer Pune Sub Division Pune
Certificate No:MAG/PH/SR/1462/2007
Issue Date:01-01-2004
12.
Name of the document on which basis caste certificate is obtained from competent authority.
Fathers Caste Certificate, Grand Fathers Birth Certificate
Affidavit
2 Of 8
Details of institution where applicant studied/studying
13.
Stage of
Education
Name of Educational
Institute
Educational
Institute Address
Duration of
Education
(Year)
From
Primary
Pune Municipal School No. 15
Primary
Pune Municipal Primary School

No 17
Agarkar High School
Secondary
Ravivar Peth Pune

411030
Rasta Peth Pune
411011
Rasta Peth Pune
411011
Caste mentioned in
educational institute's
record
To
1996
2000 Hindu Mahar
2000
2001 Mahar
2001
2010 Mahar
If applicant's father is literate, following information to be furnished

14.
Stage of
Name of Educational
Educational
Duration of
Caste mentioned in
Education
Institute
Institute Address Education (Year) educational institute's
record
Primary
Pune Municipal School No. 15
Secondary
Agarkar High School
College
Wadia Collge Of Commerce
15.
16.
Ravivar Peth Pune

411030
Rasta Peth Pune
411011
Pune Station
From
1956
To
1961 Mahar
1961
1968 Mahar
1969
1973 Mahar
If applicant/applicant's family has migrated to Maharashtra state from other State, following
information is to be furnished:Is applicant's family migrated to Maharashtra State ?
No
If yes, from which State and when (Year)?
State :N.A Year :N.A
(a) Whether scrutiny of the caste certificate of any member of the family has been done
earlier?
Yes
(b) If Validity Certificate is received (enclose attested copy) Furnish Following Details
Name of family member
Relation
with
applicant
Father
Why (Reason of Scrutiny)
Shri. Mansaram Dagadu

Service
Gaikwad
Shri Sakharam Dagadu
Paternal
Service
Gaikwad
Uncle (Kaka)
1998
(c) If Validity Certificate is rejected give its details below

17.
When
Validity
Validity
Scrutinized Certificate No Certificate
Date
1995
11234
01-10-1995
12356
01-10-1998
N.A
(a) If applicant has applied for Caste Certificate No

before any committee in the state.
(b) If yes,which committee
N.A
(c) For which Caste
N.A
Caste Category
N.A
ii
Sub Caste
N.A
(d) Date of application

(e) Committee's decision
18.
(a) Purpose of scrutiny
3 Of 8
Documents to be attached with application

19.
Following documents are attached only as per the sequence.
(A)
Important Primary Documentary Evidence
(Strike out whichever is not applicable)
Attached
Attached
Attached
Attached
Certificate by the Principal of College (As per the last para of FORM- Attached
16, Rule14)
Attached
Attached
Attached
Attached
(b-2) Any other documents supporting caste claim

attached
No
If any of the above documents are not available, then attach other relevent documents.(mention)
I am producing certified copy of above documents with my application. I declare on oath that the information furnished by
me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of
making fresh application will be of mine.
Place:
Yours,
Date :
(Signature of the Applicant's

Father/Guardian)
Applicant's signature.
4 Of 8
Document Details
Document Name
Relation
Caste
Year
Father
Mahar
10-10-1960
Father
Mahar
01-06-1962
Grandfather
Mahar
01-06-1930
I am producing certified copy of above documents with my application. I declare on oath that the information furnished by
me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of
making fresh application will be of mine.
Place:
Yours,
Date :
(Signature of the Applicant's
Father/Guardian)
Applicant's signature.
5 Of 8
Certificate to be given by Principal of the School/College
This is to Certify that Shri Kumaji Mansaram Gaikwad is a Student of this School/College in Year 2012-13 and he/she
is studying in 11th Science . His /Her name and other information is as per mentioned at number 3804 in general
register. And the Caste stated as per our general register is ........................................................................ .
(strike out if not applicable)
Place :Date:-
.............................................................
Seal and Signature of the Principal / Head Master
6 Of 8
FORM - 3
[rule 4 (1)]
AFFIDAVIT OF CLAIMANT/ PARENT(S)

(Rule 4, Order 18 of the Code of Civil Procedure, 1908)
I, .................. son / daughter of
Shri/Smt. .........................................................................................., aged ............years,
occupation................................................., residing at ................ village/
Town , , Tahsil, District ,
State here by solemnly affirm as under:2. I hereby give the genealogy tree of my family and relatives, which is as under: -
3. Other relevant submissions to be made or any essential explanation to be made, in support of Caste /Tribe
claim, including the sociological, anthropological and ethnological (anthropological moorings and ethnological
kinship), genetical trailts, of the Caste/Tribes, if any;
To the best of my knowledge and belief the information given in the application FORM -1 and in this affidavit
is based on facts and is correct.
Place:
Date:
Signature:.............................................
(Name of the applicant/claimant)
7 Of 8
FOR STUDENTS
FORM-17
[rule 14]
Affidavit to be produced along with Caste Scrutiny Application Form
I Shri/Smt.___________________________________________________________________________ age
______years, Occupation ______________________, residing at
____________________________________________________, hereby solemnly affirm today dated ____________
that Caste Certificate of my son/daughter Number _______________________ dated ______________ given by
__________________________________________________________________________ District
___________________________________ is submitted for the Scrutiny.
The documents and proofs attached with the application Form are obtained by me from Competent Authority. These
documents are true and correct and obtained by following proper procedure. No alteration / correction / change are made
in these documents. I affirm hereby that these documents are not duplicate or bogus.
*Caste Certificate of any relative from my paternal side was not invalidated by the Scrutiny Committee.
*And it is not a case that I applied before any Caste Certificate Scrutiny Committee in Maharashtra and my caste
certificate is invalidated.
I will be responsible, if the documents and proofs attached with the application form are found to be incorrect or
bogus, and I am aware that I will be liable for punishment under provision of Indian Penal Code.
I declare that the above mentioned information is true and correct, hence this affidavit.
Place :Date :-------------------------------------Signature of the Declarant
************
8 Of 8

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