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,
Bidhannagar , North 24 Parganas.
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 : SCWB11052021/4610 ( Municipality : Bidhannagar )
1. (a) Applying for : SC (b) Name of caste : RAJBANSHI
2. Full Name of Applicant : ADHIBAS MONDAL.
3. Father's Name : LATE SANNASI MONDAL 5. Contact No. : 7003968920
4. (a) Date of Birth : 10/03/1990 6. Email Id. :
(b) Place of Birth : 7. Adhar No. : XXXXXXXX7162
Village / Ward Police Station District State
MAHISHBATHAN, UDAYAN PALLY ELECTRONIC COMPLEX NORTH 24 PARGANAS WEST BENGAL

8. Address since birth (a) Present address:

Para / House No. / Ward No. / G.P. Post Office Police Station District State PIN
Road / Village
MB252,MAHISHBATHAN 28 KRISHNAPUR ELECTRONIC NORTH 24 WEST 700102
, ABAD PARA COMPLEX PARGANAS BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
MB252,MAHISHBATHAN , ABAD 28 KRISHNAPUR NORTH 24 WEST 700102
PARA PARGANAS BENGAL

9. Nationality : INDIAN 10. Religion : Hinduism 11. Sex : Male

12. Whether any of the blood relations of the applicant posseses Caste Certificate? No
If answer to point no. 12 is 'Yes':
Name of cert. holder Relation with applicant Certificate No. Date of Issue Issuing authority

13. Details of two(2) referees:

Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
SABITA MONDAL MAHISHBATHAN,MAJHER SUNAYANI DAS MAHISHBATHAN,MAJHER
PARA PARA
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 )