(ed Court Fae Stamm of Bo) au dae + [| I TT 0 Wor Ul AA He] UAW UAS Tou a The Executive Magistrate / sichucts uzatlle, ouréla, sian, From =f 2allelt = | request that a certificate in respect of reservation for ther Backward Ciasses in Civil Posts and Services under Gov. of india be granted to meg Met Wate aatel Ete Renee MLZ AA are Rl ow} <._ | Full name of the applicant meevete of tt 2_[Date of Birth 7 west audio. a ‘Complete Residential Address Faberge azatvatell yA Bell Present /eicat eaigel aie Permanent / siaall edsiaiell aia Religion / wt Caste / wile ‘Sub Caste / at wile ‘Occupational Group siealBe sell ~.__| Serial Number of the Caste in the Central List of 0.B.C.’s / azstzell ait Mutat ale RADA MAA srs wiete ¢._ | Name of father Met fl of ott Ration card No. ati oi8 ioe Electoral Roll Polling Station No. & Sr, No. FHetetet Bos sake a 5s eote Nationality / ois Place of resident / aBegell wen ‘Since when residing at above place. Boca areiell Gur yeeiet Bewg. Ue 22.Ration card No. ate si8 eiote Electoral Roll Polling Station No. & Sr. No, Hetetet Bot elke WAL SHE lake Nationality ois Place of resident / aaigell wou Since when residing at above place Beck axel Cue yrvoott eq Ue 22 BL Name of Husband wi aft ¢ ot Ration card No. atti. 8 oluz Electoral Roll Polling Station No. & Sr. No. HetBt Bes oiske A SLB sioK2 Nationality aise _ Place of resident / eeigell waa | Since when residing at above piace Beet anaall Gue yroiett Vou Ue 2 BL ‘Status of Parent{a) / Husband ste / Rete E20 Father! at “ ‘Const Posts — ww day A () Designation / AE ew “Government Service — 4, aasidl sal () Service (CentralState) ASA (hoa 2e4) |W Designation 7 @L (iy Scale of pay, including, Classification, fary. / Uae agiell sulbell (i) Date of appointment to te post. / Atel ais ard (Wage at the tine of Promotion to Class | Post (applicable) col su cell Aetou av4e1 ue ‘Employment in international Organization o.9. UN, UNICEF, WHO Abell deal silat wil. Pel 2 UN, UNICEF, WHO o Name of Organization eeu ou @ Designation 7 2 wo Period of Service (indicate Date) ts a we Yay J aural wapual (a LD A 2€ 52 ) ‘Death 7 Permaiient Incapacitation (Omit i not applicable)Daie of Death /Parmanent incapacitation puting an officer | outoF service Hell tbr 7 amu wail aAsAcl 26 atdloe Details of permanent ©) | incapacitation steal aaa Employment in Public Sector Underiaking oc M |eadz BA Al Asal ol ud Tame of Organon © | aeeuei owe @_| Designation / ala ~~ Dato of appoiriment to the post 6 | ous el ‘Armed Forces Tiludlng Para = Miltary force (his wil not include persons holding Chi (©) | Posts) Aeil / case aetller mie [@_ [Designation AA (i) [Scale orPay 7 wou eR | (gy | Professional clas (ther than these covered in Wlam Nos. 8 & C) and those angagodin trade, Business and industry eeupation Profession © [sey erecuer 10, Property Owners:- Raise wi | Agricultural land holding :- Owned by Mother, Father & Minor Children 1 [Rell auars aller + Wettell, atatt, Met WA alle oatmalell 1 [Location 7 san = | Size of holding 7 Baga = Inigated (Type of irigated land) Aue usa yst2) Y | Unsirigated = Ba Bus Percentage of rigatd land RoWnG to Sattar Ceing nit under Stata and caling ws = V |e Aes Altix Ao wr Raul endl Bead allan Alar not iower than te land holding fe Both ivigated and un-Wigated total rigated land holdings on the Mi_[ bass of conversion formula in state land coiling tw. - Reus / Bet Readel earetel ‘| Peteentage of otal irigated land heding to statutory cling mt as par(V), = Raced set anata Crops /Faut Wie79at = Vit | Plantation: 20 ¢ uot b. Location ¢ tA ” | &._Avea of Plantation alltel agin ix | Vacant land and or building in | @ Location of property = [% | Urban areas oruban | Retsete aniaiso Pape = ecomeraton wl lle 5: Deals Pee wean 6. Use to wich Ris Put 4 si 3g MO = | X_| Income / Wealth : wis / AulA nore from agyicutaral land) = ‘a. Annual family meome from all source (Excluding salari6s | pbeall is suas es UT (ue WA Bel ats oe see |b: Water ax paver Geano) (yes a copy oT heat tree ears lum a Wiad) = sf oetse 08 D at / AL (Leek AWE A Deu 3 eke] ABH ay Seq ) ef AUR ae seri WAB avo (A at AS A Ade vy 52d) “Any Other Remarks = aoe AL = Ty cently that the above particulars are tue fo the best of my knowledge and belief and that | do not belong to the Creamy Layer OBCs and eligible to be considered for the post so reserved. In the event of any information found being false or incorrect or ineligibility being dotected before or ater the selection, understand that my candidature / appointment is liable to be cancelled and | shall be lable fo such further action as may be provided under the law in force. Fwd vy GBA vey wari adel Bout well B, KAA DA EW A wee Wa eote] wAMe ze Seeinil ma WA aol Moll alle Guz Her eds cual 26 sear must AL aed statet A Rane youd mat Bue Note avai a AA g aan g Place / ea: Dated / eta = Signature ofthe Cancidate seeveiell al Enclosures = Alsi MUtaaELe SRA stOIRS wee WUD Eady ay Seat Documents produce as per Citizen Charter of Mamiatdar Otioe, Diu, ——