Ha a an (aa HHA (court fe sta 03+) Application form for Non Creamy layer Certificate - end Allan mid el was = Tame of pia Sei ‘Adress Du a ‘Site = UT. of Daman & Ow Pingode= a MOMS HT wea a Te. OFA) = = [Mobile Ko Tae Date of ih SST [elon ‘ase (Eaioed OBC Create Issued by the competent authority voit Tame of ater asband Teas wa Name of other sega ancl situs oF Parenta/ Husband sa Rea wae Source of Tre ote Icowir) Profeson/Trade/ Business/gretore Tame ‘resnation/ Department Designation” Soe oF Dae oF Depeintment ara] ea (aes ae 2a deus aaa oy oa ae Faker Tea Mother Husband cu [ouceor INCOME Remarks aT Father Ager ad holding owned by Mother, Father & Minor laren, ue Ta Pe ~ loetion ‘She ofhating =Coe TW Type ofrigaed nnd —— as ——— — V.—| Percentage of igated ond holding to stator can nit under ate nd cing as. esd ane Ta = ‘Vc land foiings both wigated and ur-vigated land holng on The basis of ‘omer mula mate ncn [ste Oita es eo ase TH Prerage oa gat andl sista lg To par eagtadnigustyadssat —_— VE [Parana |e rea ofpantaon a — "RC Wort and and or bulingin urban areas or urban agyararation [_—[reavalr narod ara — een —— “Vee to which Riepat es ee income weath: Anal fail income ama sours [exuding salaries & ocome fom | greats nd — iii nes a TER RTE wor aT — [|B Wtier tak paver (asl) yes copy of hear tree years atm befurshed) ates wea a Tae a TAS = ‘E_Whether covered in wosth tx act (exe (ye furith FT o[Saiceiiinenteadantrerucde gy —| 7 Detl of Mother & Father not required nave of marred woman Waist eo ge dan) art ad tal aE TO [1 ery ha te ahve partelars ao rust the oat oT my Know and OST wT TT do nt belong tote Creamy Layer O8Cs and eligible to be considered for he poss so reserved. {nthe even of any intormation being found flor ncrrect or ney beng detected before or after the selection, uncerstand that my eondstur appointment ibe oe aneeted and sale lle to Such further action a ay be provid under thea ond or ‘es [ey HR aad aay, ae | sede al, ook cs aa stand acd tai ate Be Wa We Oe eRe auld dole “ i a Stefi gpta———) [rere sented enero = t 4 Report oF Talati= [Tformation arish bythe applicant ore cri caret Te aad snnvel fart income othe appa from al sources sR trend aR 48) ‘Siehalure ape name oF Fa — ecards 2._| Recommendation of Cle Ofer = Recommended Won Recommend c oT i = Raed ied eal of the Ofice oate = ‘Signature of Crde Ocean ala te = ana sea ge a