Department: Welfare of Plain Tribes and Backward Classes Department

APPLICATION FORM FOR NON CREAMY LAYER CERTIFICATE

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(* Marked Fields are mandatory)
(* )
Applicants Details ( )

*Applicants Name ( ) ..

*Date of Birth ( ) ..

*Mobile Number ( )

*Father's Name ( )

*Mother's Name ( )

Spouse Name (/ )

Permanent Address ( )

*State () .

*District() .

*Sub-Division() .

*Revenue Circle ( ) .

*Village/Town(/) ..

*Post Office() ..

*Mouza() ..

*Police Station() ..

House No( ) ..

*Pin Code( ) .. (e.g 78xxxx)

Signature of the applicant

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 APPLICATION FORM FOR NON CREAMY LAYER CERTIFICATE

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Other Details ( )
Name of Caste ( ) ..
*Financial status of Parent(s) / Husband / Wife :
Earning Type of Organization (Govt./Pvt.) Name of Designation
Source Profession /Trade / Business / Organization / Post held
( ) Agriculture etc.( /Department ( )
(/ ) / (/
/) )

Mother()
Father()
Husband()
Wife()

Earning Income( ) Remarks

Source Gross Annual Income from Total ()
( ) Salary / Amount Other Source( ( )
( )
/)
Mother()
Father()
Husband()
Wife()
Supporting Documents ( )

1. *Permanent resident certificate or any other proof of residency(

)
2. *OBC/MOBC certificate issued by competent authority.(
/ )
3. *Income certificate of parents by the Circle Officer if they are agriculturists/
Income certificate from controlling authority/ Treasury Officer if retired salaried
parents.( /
/ )
4. Any other document. ( )

Signature of the applicant

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