FORM IA

SEE RULE 7BB[I]

FORM OF ON LINE APPLICATION FOR SCHEDULED CASTE / SCHEDULED TRIBE CERTIFICATE
To
The Sub-Divisional Officer / D.W.O, Kolkata & Ex-Officio Joint Director, B.C.W,
Dinhata , Cooch Behar.
Sir,
I do hereby apply for SC/ST Certificate in the following prescribed proforma, for which particulars are
given below. I hereby undertake that the information is correct to the best of my knowledge and belief and
if anything found contrary I would be liable for that.

Yours faithfully,
Date:
(Signature of applicant / gurdian in case of minor)
Application No : SCWB03022018/2588 ( Block : Dinhata-I )
1. (a) Applying for : SC (b) Name of caste : RAJBANSHI
2. Full Name of Applicant : JOY ROY
5. Contact No. : 8001423316
3. Father's Name : RABI ROY
6. Email Id. :
4. (a) Date of Birth : 14/12/2007
(b) Place of Birth : 7. Adhar No. : 684851410901

Village / Ward Police Station District State

CHOULER KUTHI DINHATA COOCH BEHAR WEST BENGAL

8. Address since birth :

(a) Present address :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
CHOULER KUTHI GOSANIMARI-1 GOSANIMARI COOCH BEHAR WEST 736145
BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN

9. Nationality : INDIAN 10. Religion : Hinduism 11. Sex : Male

12. Whether any of the blood relations of the applicant posseses Caste Certificate? Yes
If answer to point no. 12 is 'Yes':
Name of cert. holder Relation with applicant Certificate No. Date of Issue Issuing authority
BIKRAM ROY REAL BROTHER wb0302sc201800476 20/02/2018 Dinhata

13. Details of two(2) referees:

Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
MADHABCHANDRA V-CHOULER KUTHI P.O- UTTAM ROY V-CHAULER KUTHI P.O
ROY GOSANIMARI P.S-DINHATA GOSANIMARI PS-DINHATA
14. Whether the applicant or his family migrated from other State / Country? No
If point no. 14 is 'Yes': Migration Certificate No. : Date of Issue :
Address of the applicant in his/her state of origin.
Village / Ward Police Station District State Country Year

Date: ( Signarure of applicant / gurdian in case of minor )