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. sub–group
___________
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