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,
Durgapur , Paschim Bardhaman.
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 : SCWB22022021/59792 ( Block : Andal )
1. (a) Applying for : SC (b) Name of caste : MUCHI
2. Full Name of Applicant : AMALI RUIDAS
5. Contact No. : 9002252099
3. Father's Name : SHIBU RUIDAS
6. Email Id. :
4. (a) Date of Birth : 23/07/1986
(b) Place of Birth : 7. Adhar No. : 367X XXXX X201

Village / Ward Police Station District State

UKHRA Andal PASCHIM BARDHAMAN WEST BENGAL

8. Address since birth :

(a) Present address :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
UKHRA UKHRA UKHRA PASCHIM WEST 713363
BARDHAMAN 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 Female

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
AKSHAY RUIDAS NEPHEW C0023253 06/02/2012 Durgapur

13. Details of two(2) referees:

Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
DEEP RUIDAS UKHRA KAJAL RUIDAS UKHRA

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 )