CERTIFICATE – 1 ¼izek.

k i= & 1½

vuqlwfpr tkfr @ tutkfr ¼UPSC / UPST / GDSC / GDST½

¼vH;FkhZ ds tUe ftys ds ftyk eftLVªsV @ izFke Js.kh eftLVªsV }kjk izekf.kr½

;g izekf.kr fd;k tkrk gS fd Jh @ dq0 &&&&&&&&&&&& iq= @ iq=h Jh

&&&&&&&&&&&&&& fuoklh xkWo @ “kgj &&&&&&&&&& rglhy &&&& ftyk
&&&&&&&& izns”k &&&&&&& dk tUe &&&&&&& tkfr esa gqvk Fkk vkSj ;g tkfr
vuqlwfpr tkfr @ tutkfr vkns”k ¼la”kks/ku½ ,DV 1956 ds vUrxZr Hkkjr ljdkj @ mRrj
izns”k “kklu &&&&&&&&&&& ljdkj }kjk ekU; vuqlwfpr tkfr @ tutkfr gSA

vH;FkhZ ds gLrk{kj gLrk{kj

fnukad uke
LFkku eksgj
ftyk vf/kdkjh@vfrfjDr ftyk
vf/kdkjh @ flVh eftLVªsV @
ijxuk eftLVªsV @ rglhynkj
 CERTIFICATE – 2 ¼izek.k i= & 2½
¼ uksV % vH;FkhZ /;ku nsa fd m0iz0 ds vU; fiNM+s oxZ ds fy, tkfr izek.k vizSy 01]
2023 ;k mlds i”pkr dk cuk gqvk gksuk vko”;d gSA ½

mRrj izns”k ds vU; fiNM+s oxZ ds fy, tkfr izek.k i= dk izk:i ¼ UPBC / GDBC½

;g izekf.kr fd;k tkrk gS fd Jh @Jherh @ dq0 &&&&&&&&&&&& iq= @

iq=h Jh &&&&&&&&&&&&&& fuoklh xkWo @ “kgj &&&&&&&&&& rglhy
&&&&&& ftyk &&&&&&&&mRrj izns”k jkT; dh &&&&&&& fiNM+h tkfr ds O;fDr
gSaA ;g tkfr mRrj izns”k yksd lsok vuqlwfpr tkfr;ksaA vuqlwfpr tutkfr;ksa rFkk fiNM+s
oxksZ ds fy, vkj{k.k vf/kfu;e] 1994 dh vuqlwph&1 ds vUrxZr ekU;rk izkIr gSA

;g Hkh izekf.kr fd;k tkrk gS fd Jh@Jherh@dqekjh &&&&&&&& mDr

vf/kfu;e 1994 dh vuqlwph&2 ¼vf/klwpuk la[;k &22@16@92&dk 02@1995 Vh0lh0
fnukad 8 fnlEcj] 1995 }kjk ;Fkk la”kksf/kr½ ls vkPNkfnr ugha gSA

Jh @Jherh@dqekjh&&&&&&&&&& rFkk vFkok mudk ifjokj mRrj izns”k ds

xzke &&&&&&&&&&& uxj &&&&&&&&& ftyk &&&&&&&& esa lkekU;r;k jgrk
gSA

vH;FkhZ ds gLrk{kj gLrk{kj

fnukad uke
LFkku eksgj
ftyk vf/kdkjh@vfrfjDr ftyk
vf/kdkjh @ flVh eftLVªsV @
ijxuk eftLVªsV @ rglhynkj
 CERTIFICATE – 3 ¼izek.k i= & 3½
¼uksV % izek.k i=&3 vH;FkhZ ds ekrk@firk ds uke ij cuk gksuk pkfg, D;ksafd vH;FkhZ ftUgkssaus
vgZdkjh ijh{kk m0iz0 ds ckgj fLFkr fdlh fo|ky; ls mRrh.kZ dh gS ijUrq muds ekrk@firk
m0iz0 ds ewy@LFkkbZ fuoklh gSa] izos”k gsrq vgZ gSaA½

mRrj izns”k ds ewy@lkekU; fuoklh ds iq=@iq=h ¼UPGD / GDSC / GDST / GDBC½

;g izekf.kr fd;k tkrk gS fd Jh @Jherh ¼vH;FkhZ ds firk@ekrk dk uke

&&&&&&&&&firk@ekrk Jh@dq0 ¼vH;FkhZ dk uke½ &&&&&&&&&&&& m0iz0 ds
xkWo@”kgj &&&&&&&&&& rglhy &&&&&& ftyk &&&&&&&& ds ewy fuoklh gSa
rFkk Jh@dq0 ¼vH;FkhZ dk uke½ &&&&&&&&&&&&&&& vius firk@ekrk ij iw.kZr;k
vkfJr gSaA mDr irs ij Jh@dq0 ¼vH;FkhZ dk uke½&&&&&&&&&&&& ds ekrk@firk
lkekU;r% fuokl djrs gSaA

vH;FkhZ ds gLrk{kj ftyk eftLVsªV ds gLrk{kj

fnukad iwjk uke
LFkku inuke
eqgj ¼ftyk eftLVªsV dh lhy½

ftyk eftLVªsV vFkok ftyk eftLVsªV }kjk vf/kd`r vij ftyk eftLVªsV@lc fMohtu
eftLVsªV }kjk izek.k i= gh ekU; gksaxs tks “kk0vk0 la0 &157@rhu&2003&77¼II½@83
fnukad 18 Qjojh] 2003 ds v/khu tkjh fd;k tk;sxkA
 CERTIFICATE – 4 ¼izek.k i= & 4½ ¼Sub-Category UPFF½

mRrj izns”k yksd lsok ¼”kkjhfjd :i ls fodykax@fnO;kax] Lora=rk laxzke lsukuh ds vkfJrksa
vkSj HkwriwoZ lSfudksa ds fy, vkj{k.k½ vf/kfu;e] 1993 ds vuqlkj LorU=rk laxzke lsukuh ds
vkfJr ds izek.k i= dk izi=

izekf.kr fd;k tkrk gS fd Jh @Jherh ¼Lora=rk laxzke lsukuh dk uke½ &&&&&&&&&

fuoklh xzke &&&&&&&&&rglhy &&&&&&uxj &&&&&&&&&ftyk
&&&&&&&&m0iz0 yksd lsok ¼”kkjhfjd :i ls fodykax@fnO;kax] Lora=rk laxzke lsukuh
gS vkSj Jh@Jherh@dq0 ¼vkfJr vH;FkhZ dk uke½ &&&&&&&&&&&&&
iq=@iq=h@ikS=@vfookfgr ikS=h mijkafdr vf/kfu;e] 1993 ds vuqlkj ds gh izko/kkuksa ds
vuqlkj mDr Jh@Jherh ¼Lora=rk laxzke lsukuh½ &&&&&&&&& ds vkfJr gSaA

fnukad ftyk eftLVsªV ds gLrk{kj

LFkku iwjk uke ,oa inuke
eqgj ¼ftyk eftLVªsV dh lhy½
 CERTIFICATE – 5 ¼izek.k i= & 5½
¼uksV% izek.k i= ds mijksDr nksuksa Hkkxksa dks Hkjk tkuk ,oa izekf.kr fd;k tkuk vfuok;Z gSA½

mRrj izns”k @lsuk ny ¼ Sub-Category UPAF½

¼vafre ;wfuV ds vkfQlj dekfUMax@ftyk lSfud dY;k.k cksMZ }kjk izekf.kr½

;g izekf.kr fd;k tkrk gS fd Jh @Jherh ¼vH;FkhZ ds firk vFkok ekrk dk uke½

&&&&&&&&& fuoklh xkao@”kgj &&&&&&&&&rglhy &&&&&& ftyk
&&&&&&&&m0iz0] ds fnukad &&&&&&&& dks lsok fuo`Rr ¼Superannuated½ @ ;q) esa
ekjs x;s@viax gks x;s@mRrj izns”k esa orZeku esa rSukr gSA os Hkkjrh;
Fkylsuk@tylsuk@ok;qlsuk ds LFkku &&&&&&&& fnukad &&&&&&& ls fnukad
&&&&& rd dk;Zjr Fks@gSaA

fnukad ;wfuV dekfUMax vkfQlj ds gLrk{kj

LFkku uke
eqgj

¼ftyk eftLVsªV }kjk izekf.kr½

;g izekf.kr fd;k tkrk gS fd Jh @dq0¼vH;FkhZ½ ------------------------------- fuoklh -----------------------------

mRrj izns”k xkao@”kgj &&&&&&&&&rglhy &&&&&& ftyk &&&&&&&&mijksDr
lsuk ny ds lsok fuo`Rr ¼Superannuated½ @ ;q) esa ekjs x;s ;k viax gks x;s deZpkjh tks
mRrj izns”k ds LFkk;h fuoklh gSa@Fks] ds iq=@iq=h gSa vFkok izos”k ijh{kk dh frfFk dks
mRrj izns”k Hkkjrh; Fkylsuk@ty lsuk@ok;qlsuk es dk;Zjr Fks@gSaA

fnukad rglhynkj @ ftyk eftLVªsV ds gLrk{kj

LFkku uke
eqgj
 CERTIFICATE – 6 ¼izek.k i= &6½ ¼Sub-Category UPPH½
“kkjhfjd fodyakx ds vf/keku ds fy, izek.k i= ¼eq[; fpfdRlk vf/kdkjh }kjk izekf.kr½

1- ;g izekf.kr fd;k tkrk gS fd Jh @dq0 ¼vH;FkhZ½ &&&&&&&&&iq=@iq=h Jh

¼firk @ ekrk dk uke½----------------------------------------------------------uhps fy[ks dkj.kksa ls “kkjhfjd
:i ls fodykax@fnO;kax gSA
2- vH;FkhZ dh mijksDr fodykaxrk@fnO;kaxrk dks fuEu izdkj dh fodykaxrk dh Js.kh
esa j[kk tk ldrk gSA
¼d`i;k ✓ dk fu”kku yxk;sa½
Type I Minimum 40% permanent Visual impairment
Type II Minimum 40% permanent Locomotors disability
Type III Minimum 40% permanent speech and Hearing impairment

3- ;g Hkh izekf.kr fd;k tkrk gS fd mijksDr fodyakx@fnO;kax fLFkfr vH;FkhZ ds

bath0 f”k{kk izkIr djus esa ck/kd ugha gksxhA

fnukad ftyk eq[; fpfdRlkf/kdkjh ds gLrk{kj

LFkku uke
eqgj
 CERTIFICATE – 7

CHARACTER CERTIFICATE FROM THE HEAD OF THE INSTITUTION LAST

ATTENDED

This is to certify that Sri/Km. ____________________________ has been a bonafide student of

______________________________ from _________________________ to ______________

and has passes / appeared at the ______________________ examination in the year __________

Proctorial Reports:
1. Has he / she involved himself / herself if any act of indiscipline? Yes / No
2. Has he / she been warned, fined or punished for any act of indiscipline ? Yes / No
3. Has he / she been restricted or expelled from Hostel of College for any reason? Yes / No
4. Has he / she been involved in any act of indiscipline outside the college campus like group
clashes or fraction fights etc. Yes / No
5. Has he / she been addicted to drugs or intoxicants? Yes / No

General remarks (Please state your assessment of the student)

Date: ___________
Signature of Head of the Institution: ____________________________
Name: ____________________________
Designation: ____________________________
 CERTIFICATE - 8
* FROMAT FOR MEDICAL CERTIFICATE *
(To be obtained from a Chief Medical Officer or Medical Officer of Harcourt Butler Technical University, Kanpur)
This certificate has to be sunbmited at the time of admission in the University

Name of Candidate: Age: Sex:

Father's Name: Mother Name:

Program: B.Tech. JEE (Main) 2023 Roll No. Rank.

]
MCA NIMCET 2023 Roll No. Rank

M.Tech. PhD Category: Subcategory & Weightage:

(To be filled in by the Candidate)

L.T. M.I. V Colour Vision:

i o
Height Weight Chest Abdomen Without Glass:
s n
i With Glass:

History Operation Koch's Colics B.P.

Seizures Asthma Piles Diabetes

E Pulse Tonsil DNS Hernia

x
Pallor L.Nodes CSOM Hydrocele
a
i
m
o Cardiovascular
i CNS
n
n
Respiratory GIT
a
t Genitourinary Others

Type-I: Minimum 40% permanent Visual impairment

Is the Candidate Physically Handicapped / Disabled: If
yes, type of handicap / disability:
(Please tick the type of handicap / disability)
Type-II: Minimum 40% permanent Locomoter disability
Type-III: Minimum 40% permanent speech and Hearing
important

Any other finding:

Certified that the candidate is physically fit / unfit / temporally disqualified to pursue engineering studies

Date: ___________________

Signature of The Signature of Chief Medical

________________________ _____________________________
Candidate Officer:
Name: _____________________________
Designation: _____________________________
 CERTIFICATE – 9

UNDERTAKING BY CANDIDATE FOR MEDICAL FITNESS

I certify that I do not have any physical handicap / disability which would hinder my pursuit of

study in the courses in which I am seeking admission. If at any stage, it is found that I have a

physical handicap / disability which hinder my pursuit of study, my admission will be cancelled.

I will produce medical fitness certificate from a C.M.O. / C.M.S. at the time of physical reporting

at HBTU, Kanpur.

Date: Signature of the candidate

Counter signed by father / guardian

 CERTIFICATE – 10 ¼izek.k i= & 10½

vf[ky Hkkjrh; lsok ds m0iz0 dSMj ds vf/kdkfj;ksa @ deZpkfj;ksa gsrq

izekf.kr fd;k tkrk gS fd Jh @Jherh ¼vH;FkhZ ds ekrk @ firk dk uke½ --------------

-------------------------------------------- inuke ----------------------------------- foHkkx dk uke --------------------------------
---------- dSMj la0 ------------------------------------------ vf[ky Hkkjrh; lsok ds m0iz0 dSMj ds
vf/kdkjh @ deZpkjh gS rFkk orZeku esa bl dk;kZy; esa dk;Zjr gSA ;g izek.k i=
buds iq=@iq=h ¼vH;FkhZ dk uke½-------------------------------------------------------------------------- dks
Harcourt Butler Technical University, Kanpur ds vUrxZr izos”k gsrq iznku fd;k
tkrk gSA

fnukad % laLFkk ds eq[; vf/kdkjh ds gLrk{kj

uke ,oa inuke
LFkku % eqgj
 CERTIFICATE – 11

¼uksV % vH;FkhZ /;ku nsa fd m0iz0 ds vkfFkZd :i ls detksj vH;fFkZ;ksa ds fy, vk; izek.k
i= vizSy 01] 2023 ds i”pkr~ dk cuk gqvk gksuk vko”;d gSA½

¼Income Certificate for Tuition Fee Waiver Scheme½

{ks=h; Hkwy[s k fujh{kd rFkk ys[kiky dh tkap fjiksZV ds vk/kkj ij izekf.kr fd;k
tkrk gS fd &&&&&&&&&&&&&&&&&&& ¼vkosnd ds vfHkHkkod@ekrk@firk
dk uke½ lqiq= &&&&&&&&&&&&&&&&&& fuoklh@xzke &&&&&&&&&
ijxuk&&&&&&&&& rglhy &&&&&&&&& uxj &&&&&&&& ftyk
&&&&&& jkT; &&&&&&&&& ds Lo;a dh ekfld vk; :i;k &&&&&& rFkk
okf’kZd vk; :i;k &&&&&&&&&&&&&&& gSA ys[kiky dh fjiksVZ ds vuqlkj
vk; dk Jksr &&&&&&&&&&& gSA

LFkku % rglhynkj ds gLrk{kj

uke
eqgj

¼uksV% ekrk&firk dh lHkh Jksrksa ls vk; :0 8-00 yk[k ;k mlls U;wu gksuh pkfg,A½
 CERTIFICATE – 12
(Certificate issued after 01.04.2023)

Performa for Economically Weaker Section (EWS) Certificate

U.P. Government
INCOME & ASSET CERTIFICATES TO BE PRODUCED BY ECONOMICALLY
WEAKER SECTIONS

Certificate No.: ____________________ Issuing Date: ________________

Valid for the Year: ____________________

1. This is to be certify that Shri / Smt. / Kumari __________________________ son

/daughter / wife of _____________________________ permanent resident of
_______________________________________________________, Village / Street
_______________________, Post Office _________________________, District
_______________ in the State / Union Territory __________________ Pin Code
_______________ whose photograph is attested below belongs to Economically Weaker
Sections, since the gross annual Income* of his “ family”** is below Rs. 8 lakh (Rupees
Eight Lakh only) for the financial year _________________. His / her family does not
own or posses any of the following assets***:
a) 5 acres of agricultural land and above;
b) Residential flat of 1000 sq. ft. and above;
c) Residential plot of 100 sq. yards and above in notified municipalities;
d) Residential plot of 200 sq. yards and above in acres other than the notified
municipalities.
2. Shri / Smt. / Kumari ______________________________ belongs to the
_____________________ caste which is not recognized as a Scheduled Caste, Scheduled
Tribe and Other Backward Classes (list of U.P. Government).

Signature with seal of office ___________________________

Name ___________________________
Designation ___________________________

Recent Passport
size attested
photograph of the
applicant

* Income covered all source i.e. salary, agriculture, business, profession, etc.
** The term “Family” for this purpose include the person who seeks benefits of reservation,
his / her parents and siblings below the age of 18 years as also his /her spouse and
children below the age of 18 years.
*** The property held by a “Family” in different locations and different places / cities have
been clubbed while applying the land or property holding test to determine EWS status.
 CERTIFICATE – 14
Form of certificate to be produced by Other Backward Classes applying for appointment to posts / admission to Central
Educational Institutions (CEIs), Under the Government of India

This is to certify that Shri / Smt. / Kum* _________________________________________ son / daughter* of Shri / Smt.*
____________________________________ of village / Town* ___________________________ District /
Division*______________________ in the ______________________ State belongs to the
__________________________________

Community which is recognized as a backward class under :

i. Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of India Extraordinary Part I Section I
No. 186 dated 13/09/93.
ii. Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India Extraordinary Part I Section I No.
163 dated 20/10/94.
iii. Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India Extraordinary Part I Section I No. 88
dated 25/05/95.
iv. Resolution No. 12011/96/94-BCC dated 9/03/96.
v. Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India Extraordinary Part I Section I No.
210 dated 11/12/96.
vi. Resolution No. 12011/13/197-BCC dated 03/12/97.
vii. Resolution No. 12011/99/94-BCC dated 11/12/97.
viii. Resolution No. 12011/68/98-BCC dated 27/10/99.
ix. Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India Extraordinary Part I Section I no.
270 dated 06/12/99.
x. Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India Extraordinary Part I Section I
No. 71 dated 04/04/2000.
xi. Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India Extraordinary Part I Section I
No. 210 dated 21/09/2000.
xii. Resolution No. 12015/9/2000-BCC dated 06/09/2001.
xiii. Resolution No. 12011/1/2001-BCC dated 19/06/2003.
xiv. Resolution No. 12011/4/2002-BCC dated 13/01/2004.
xv. Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of India Extraordinary Part I Section I
No. 210 dated 16/01/2006.
xvi. Resolution No. 12011/14/2004-BCC dated 12/03/2007 published in the Gazette of India Extraordinary Part I Section I
No. 67 dated 12/03/2007.
xvii. Resolution No. 12015/2/2007-BCC dated 18/08/2010.
xviii. Resolution No. 12015/13/2010-BCC dated 08/18/2011.

Shri / Smt./ Kum. __________________________________and / or his family ordinarily reside(s) in the

__________________________ District / Division of ____________________ State. This is also to certify that he / she does not
belong to the persons/ sections (Creamy Layer) mentioned in Column 3 of the Schedule to the Government of India, Department
of Personnel & Training O.M. No. 36012/22/93-Estt. (SCT) dated 08/09/93 which is modified vide OM No. 36033/3/2004 Estt.
(Res.) dated 09/03/2004, further modified vide Om No. 36033/3/2004-Estt. (Res.) dated 14/10/2008 or the latest notification of
the Government of India.

Dated :
District Magistrate / Deputy Commissioner / Competent Authority
Seal

* Please delete the word(s) which are not applicable.

NOTE :
(a) The term ‘Ordinarily resides’ used here will have the same meaning as in Section 20 of the Representation of the
People Act, 1950.
(b) The authorities competent to issue Caste Certificates are indicated below :
(i) District Magistrate / Additional Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner
/ Deputy Collector/ Ist Class Stipendiary Magistrate / Sub-Divisional magistrate / Taluka Magistrate / Executive
Magistrate / Extra Assistant Commissioner (Not below the rank of Ist Class Stipendiary Magistrate)
(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.
(iii) Revenue Officer not below the rank of Tehsildar
(iv) Sub-Divisional Officer of the area where the candidate and / or his family resides.