Department : Welfare of Plain Tribes and Backward Classes

APPLICATION FOR CASTE CERTIFICATE

( জজততৰ পমজন পতৰ বজবব আববদন )
(*Marked Fields are mandatory)
(* চচহযযক তথথবববৰ ববধথতবমমলক)

Applicant’s Details(আববদনকজৰৰৰ তবৱৰণ)

*Application For (আববদন) : SC/ST(H)/ST(P)/OBC/MOBC

*Applicant's Name (আববদনকবৰৰৰ নবম) : Mr/Mrs/Miss/Others.................................................

......................................................................................
*Applicant’s Mobile No (মববইল নমৰ ) : ................................................................................

*Date of Birth (জনৰ তবচৰখ) : ..............................................................................

*Applicant’ s Caste/Tribe/Community
(আববদনকবৰৰৰ জবচত/জনজবচত/জনবগবষৰ) :...............................................................................
Sub-Category (উপবশণৰ) :..............................................................................

*Father's Name (চপততৰ নবম) : ...............................................................................

*Mother's Name (মবততৰ নবম) : ...............................................................................

EPIC No(এচপক নন) :...................................................................................

Email (ইবমইল) : ...........................................................................

Address (তঠকনজ)

Address Line 1 (চঠকনবৰ পথম শবৰৰ) : ...................................................................................

Address Line 2 (চঠকনবৰ চদতৰয় শবৰৰ) : ...................................................................................

*State (ৰবজথ) : ..................................................................................

*District (চজলব) : ..................................................................................
*Subdivision (মহকযমব) :..................................................................................
* Circle Office (চক) : ..................................................................................
* Mouza (মমমজব) : ..................................................................................
* Village (গবওও) : ..................................................................................
* Police(থবনব) : ..................................................................................
*Post Office (ডবকঘৰ) : ..................................................................................
*Pin Code (চপন নন) : ..................................................................................

Attachment Document (সসলগ নতথ)

• Applicant's Photo (আববদনকবৰৰ ফবটব)
• Proof of Date of Birth(জন তবচৰখৰ পমবন পত)
(One of Birth Certificate/Aadhar Card/PAN/Admit Card issued by any recognized
Board of Applicant)
• Proof of Residence(বসৱবসৰ পমবন পত) (One of Permanent Resident Certificate/Aadhar
Card/EPIC/Land Document/Electricity Bill,Ration Card of Applicant or Parent)
• Caste certificate of father( আববদনকবৰৰৰ চপততৰ জবচতৰ পমবন পত ) / Recommendation of
authorize caste/tribe/community organization notified by state Government(ৰবজথ চৰকবৰৰ
জবননৰৰ মযববগ সৰকতচতপৰবপ জবচত/জনজবচত/জনবগবষৰয় সনগঠনৰ সনচত পত)
• Any other document ( Voter List, Affidavit ,Existing Caste Certificate etc. ) (অনথ নচথ
,মভবটবৰ চলষ, শপতনবমব, চবদথমবন জবচতৰ পমবন পত, ইতথবচদ)
• Upload Scanned Copy of the Application Form ( ইউজবৰ ফৰৰমখন সনলগ কৰব) .

I hereby declare that the information given above are true and correct to the best of my
knowledge and belief and in the event of any information being found false or incorrect my Caste
Certificate will be liable to be cancelled.I also understand that criminal case may be filed aganist me
for submission of false information and or wrong/false/forged documents.

Date :..................................... Signature of Applicant

Place :..................................... (আববদনকজৰৰৰ সজকৰ)