FORM IA

SEE RULE 7BB[I]

FORM OF ON LINE APPLICATION FOR OTHER BACKWORD CLASS
To
The Sub-Divisional Officer / D.W.O, Kolkata & Ex-Officio Joint Director, B.C.W,
Jangipur , Murshidabad.
Sir,
I do hereby apply for OBC 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 : OBCWB07022021/35691 ( Block : Suti-I )
1. (a) Applying for : OBC-A (b) Name of caste : Dhanuk
2. Full Name of Applicant : DIPANKAR MONDAL
: Father's Name
3. : DHARANI MONDAL 5. Contact No. : 938241206
4. (a) Date of Birth : 05/10/2008 6. Email Id. :
(b) Place of Birth : 7. Aadhaar No. : XXXXXXXX0658
Village / Ward Police Station District State
AMAR PUR SUTI MURSHIDABAD 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
AMAR PUR HARUA KANAI GHAT SUTI MURSHIDABAD WEST 731222
BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
AMAR PUR HARUA KANAI GHAT MURSHIDABAD WEST 731222
BENGAL

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

12. Whether any of the blood relations of the applicant posseses Caste Certificate? Yes
If answer to point no. 12 is 'Yes':
Name of cert. holder Relation with applicant Certificate No. Date of Issue Issuing authority
BIREN MONDAL BIG FATHER 02507 02/11/1998 JANGIPUR

13. Details of two(2) referees:

Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
KANGRES MONDAL VILL- AMAR PUR,P. O- KANAI MAHESH MONDAL VILL- AMAR PUR,P. O-
GHAT P. S- SUTI, DIST-MSD, KANAI GHAT P. S- SUTI,
PIN- 731222 No DIST-MSD,
14. Whether the applicant or his PIN- 731222
family migrated from other State / Cou
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 )