Court Fee Stamp of Rs. 2.

00

APPLICATION FOR NON CREAMY LAYER CERTIFICATE

1. Name of Applicant :

2. Address :

Village /Ward Town / GP

Post Office Mouza

Revenue Circle Police Station

3. Date of Birth

4. Caste (enclose caste certificate) :

5. Name of Father /Husband :

6. Name of Mother :

7. Financial status of Parent(s) / Husband / Wife :

Earning Source Type of Organization Name of Organization / Designation / Post held

(Govt./Pvt.) Department
Profession /Trade /
Business / Agriculture
etc..
Mother
Father
Husband
Wife

Earning Source Income Remarks

Gross Annual Income from Total
Salary / Amount other source
Mother
Father
Husband
Wife

8. Recent Passport Size Photograph :

9. Pay slip /salary Certificate (if employed) :

10. Report of Circle Officer :

11. I certify that the above particulars are true to the best of my knowledge and belief and
that I do not belong to the Creamy Layer OBCs and eligible to be considered for posts so
reserved. In the event of any information being found false or incorrect or ineligibility being
detected before or after the selection. I understand that my candidature / appointment is
liable to be cancelled and I shall be liable to such further action as may be provided under
the law.

Place : Signature of the Applicant

Date :