The form ofcertificate to beproducedbyScheduled Caste/ Scheduled Tribe candidates

applyingforappointmenttopostsundertheGovernmentofIndia.

'This is to certify that Shri/Shrimati/Kumari* ...........................................

son/daughter*of .................................................... ofvillage/town*.
.................................................. inDistrict/Division*................. ofthe State/Union

Territory*

...........................................................belongstothecaste/tribe*which
isrecognizedasScheduledCaste/ScheduledTribe*under:

@theConstitution(ScheduledCastes)Order,1950
@theConstitution(ScheduledTribes)Order,1950
@the Constitution (Scheduled Castes)(Union Territories)Order, 1951
@.the Constitution (Scheduled Tribes) (Union Territories)Order, 1951
[asamendedbytheScheduledCastesandScheduledTribesList(Modification)Order,1956;the
BombayReorganisationAct,1960;thePunjabReorganisationAct,1966;theStateofHimachal
PradeshAct,1970;andtheNorthEasternAreas(Reorganisation)Act,1971andtheScheduled
CastesandScheduledTribesOrders(Amendment)Act,1976,theStateofMizoramAct,1986the
StateofArunachalPradeshAct,1986andtheGoa,DamanandDiu(Reorganisation)Act,1987.]
@theConstitution(JammuandKashmir)ScheduledCasteOrder,1956
@theConstitution(AndamanandNicobarIslands)ScheduledTribesOrder,1959asamended
bytheScheduledCastesandScheduledTribesOrder(Amendment)Act,1976.
@ theConstitution(DadraandNagarHaveli)ScheduledCastesOrder,1962.
@theConstitution(DadraandNagarHaveli)ScheduledTribes Order,1962.
@ theConstitution(Pondicherry)ScheduledCastes Order,1964.
@ theConstitution(UttarPradesh)ScheduledTribes Order,1967.
@ the Constitution (Goa, Daman and Diu) Scheduled Castes Order,1968.
@ the Constitution (Goa, Daman and Diu) Scheduled Tribes Order,l968.
@ theC onstitution (Nagaland) Scheduled Tribes Order,1970.
@ the Constitution (Sikkim) Scheduled Castes Order, 1978 @ the Constitution (Sikkim)
ScheduledTribesOrder, 1978.
@theConstitution(Jammu&Kashmir)ScheduledTribesOrder,1989
@theConstitution(SC)Order(Amendment)Act,1990.
@theConstitution(ST)Order(Amendment)Act,1991.
@theConstitution(ST)Order(SecondAmendment)Act,1991.
@the Scheduled Castes and Scheduled Tribes Orders(Amendment)Act,2002.
@theConstitution(ScheduledCastes)Order(Amendment)Act,2002.
@theConstitution(ScheduledCastesandScheduledTribes)Orders(Amendment)Act,2002.
@the Constitution (Scheduled Castes) Orders (SecondAmendment)Act,2002.@


%2. ApplicableinthecaseofScheduledCastes/ScheduledTribespersonswhohavemigrated
fromoneState/UnionTerritoryAdministrationtoanother.

ThiscertificateisissuedonthebasisoftheScheduledCastes/Scheduled Tribes
certificate*issued to Shri/ Shrirmati*............................................... father/mother of Shri/
Shrimati/Kumari*

..............................................of

village/

town*

......................

.................................... inDistrict/Division*...............................................oftheState/Union
Territory* ............................................... who belongs to the .............................................caste/
tribe* which is recognised as a Scheduled Caste/Scheduled Tribe* in the State/Union
Territory.......................issuedbythe.....................................................................dated................

%3. Shri/Shrimati/Kumari*...................................................... and/or* his/her* family

ordinarily reside(s) in village/. town*..................................................................................... of
District/Division*.....................................oftheState/UnionTerritory*of.....................................

Signature..................

**Designation...............(WithSealofOffice)
Place:...................................State/UnionTerritory*...........................
Date:................................
*Pleasedeletethewordswhicharenotapplicable.
@PleasequotespecificPresidentialorder.
%Deletetheparagraphwhichisnotapplicable.
NOTE:Theterm"Ordinarilyreside(s)"usedherewillhavethesamemeaningasinSection20
oftheRepresentationofthePeopleAct,1950.
**Listofauthoritiesempoweredtoissue ScheduledCaste/ScheduledTribe/OBCCertificates.
(i)
District
Magistrate/Additional
District
Magistrate/
Collector/Deputy
Commissioner/Additional DeputyCommissioner/Deputy Collector/1st Class Stipendiary
Magistrate/SubDivisional Magistrate/Taluka Magistrate/ Executive Magistrate/Extra
AssistantCommissioner.(notbelowtherankof1stClassStipendiaryMagistrate).
(ii) Chief Presidency Magistrate/Additional ChiefPresidencyMagistrate/Presidency
Magistrate.
(iii)RevenueOfficersnotbelowtherankofTehsildar.
(iv)SubDivisionalOfficeroftheareawherethecandidateand/orhisfamilynormallyresides.

The form of certificate to be produced by Other Backward Classes candidates applying for
appointmenttopostsundertheGovernmentofIndia.

ThisistocertifythatShri/Shrimati/Kumari*...................................................son/daughter*
of Shri ...................................... ........... of village/town*......................... in District/
Division*:....................................oftheState/UnionTerritory*.....................................belongsto
the..............................community which is recognised as a backward classunder:

@Government of India, Ministry of Welfare Resolution No. 120l1/68/93BCC(C) dated 10th

September,1993publishedintheGazetteofIndiaExtraordinaryPartI,SectionI,No.186dated
the13thSeptember,1993.
@Govemment of India, Ministry of Welfare Resolution No. 12011/9/94BCC dated 191094,
publishedintheGazetteof India Extraordinary Part I, Section I, No. 163 dated20101994.
@Govemment of India, Ministry of Welfare Resolution No. 120l1/7/95BCC dated 24595,
publishedintheGazetteofIndia Extraordinary Part I, Section I, No. 88 dated2551995.
@GovernmentofIndia,MinistryofWelfareResolutionNo.12011/96/94BCCdated9thMarch,
1996 published in Gazette of India Extraordinary Part I, Section I, No. 60 dated 11th
March,1996.
@Government of India, Ministry of Welfare Resolution No. 12011/44/96BCC dated 6th
December,1996publishedintheGazetteofIndiaExtraordinaryPartI,SectionI,No.210dated
11thDecember,1996.
@Government of India, Ministry of Welfare Resolution No. 12011/13/97BCC dated 3rd
December,1997publishedintheGazetteofIndiaExtraordinaryPartI,SectionI,No.239dated
the17thDecember,1997.
@Govemment of India, Ministry of Welfare Resolution No. 12011/99/94BCC dated the 11th
December,1997publishedintheGazetteof IndiaExtraordinaryPartI,SectionI,No.236dated
the12thDecember,1997.
@Government of India, Ministry of Social Justice and Empowerment Resolution No.
12011/68/98BCCdatedthe27thOctober,1999 publishedintheGazetteofIndiaExtraordinary
Part I, Section I, No.241 dated the27th October, 1999.
@Government of India, Ministry of Social Justice and Empowerment Resolution No.
1201l/88/98BCCdatedthe6thDecember,1999publishedintheGazetteofIndiaExtraordinary
Part I,
Section I, No.270 dated the6th December, 1999.
@Government of India, Ministry of Social Justice and Empowerment Resolution No.
1201l/36/99BCC dated the 4th April, 2000 published in the Gazette of India
Extraordinary Part I, Section I, No. 71 dated the4thApril,2000.
@GovernmentofIndia,MinistryofSocialJusticeandEmpowermentResolutionNo.12011/44/99
BCCdatedthe21stSeptember,2000publishedintheGazetteofIndiaExtraordinaryPartI,SectionI,
No.210datedthe21stSeptember,2000.
@GovernmentofIndia,MinistryofSocialJusticeandEmpowermentResolutionNo.
12015/9/2000BCCdatedthe6th September, 2001 published in the Gazette of India
ExtraordinaryPartI,SectionI,No.246datedthe6thSeptember,2001.
@Government of India. Ministry of Social Justice and Empowerment Resolution No.
12011/l/2001BCCdated19th June,2003publishedintheGazetteofIndiaExtraordinaryPart I,
SectionI,No.151dated20thJune,2003.
@Government of India, Ministry of Social Justice and Empowerment Resolution No.
12011/4/2002BCCdated13thJanuary,2004publishedintheGazetteofIndiaExtraordinary,Part
I,SectionI,No.9dated13thJanuary,2004.
@Government of India, Ministry of Social Justice and Empowerment Resolution No.
12011/9/2004BCCdated16thJanuary,2006publishedintheGazetteofIndiaExtraordinary,Part
I,SectionI,No.10dated16thJanuary,2006.

@Government of India, Ministry of Social Justice and Empowerment Resolution No.

12011/14/2004BCCdated12thMarch,2007publishedintheGazetteofIndiaExtraordinary,Part
I,SectionI,No.67dated12thMarch,2007.

Shri/Shrimati/Kumari*...........................................and/or*his/her* family ordinarily

reside(s) in village/town*..................................ofDistrict/Division*ofthe........................
State/UnionTerritory*of................................................Thisisalsotocertifythathe/she*does
notbelongtothepersons/sections* (Creamy Layer) mentioned in column 3 of the
ScheduletotheGovernmentofIndia,DepartmentofPersonnel&TrainingO.M.No.36012/22/93
Estt.(SCT)dated891993,O.M.No.36033/3/2004Estt.(res.)dated9thMarch,2004andO.M.
36033/3/2004Estt.(Res)dated14102008.

Signature................................

**Designation............................(withsealofoffice)
Place...................
Date...................

Note1:TheformatofundertakingtobefurnishedalongwiththeDAFbyOtherBackwardClass
candidates applying for appointment to post under the Government of India, is available as
AnnexureVI.
Note2:CreamylayerclauseinrespectofOBCcandidatesmustbeasperOMNo.36033/3/2004
Estt(Res)dated14102008.
Note:Thetermordinarilyreside(s)usedherewillhavethesamemeaningasinSection20
oftheRepresentationofthePeopleAct,1950.
*Pleasedeletethewordswhicharenotapplicable.
@Strikeoutwhicheverisnotapplicable.
**Listofauthoritiesempoweredtoissue ScheduledCaste/ScheduledTribe/OBCCertificates.
(i)
District
Magistrate/Additional
District
Magistrate/
Collector/Deputy
Commissioner/Additional DeputyCommissioner/Deputy Collector/1st Class Stipendiary
Magistrate/SubDivisional Magistrate/Taluka Magistrate/ Executive Magistrate/Extra
AssistantCommissioner.(notbelowtherankof1stClassStipendiaryMagistrate).
(ii) Chief Presidency Magistrate/Additional ChiefPresidencyMagistrate/Presidency
Magistrate.
(iii)RevenueOfficersnotbelowtherankofTehsildar.(iv)SubDivisionalOfficeroftheareawhere
thecandidateand/orhisfamilynormallyresides.

FORMATOFUNDERTAKINGTOBEFURNISHEDBYOBCCANDIDATES.
UNDERTAKING

I, son/daughter of Shri .. Resident

of village/town/ city..districtstate.hereby declare
that I belong to the..community which is recognized as a backward
class by the Government of India for the purpose of reservation in services as per
orders contained in Department of Personnel and Training Office Memorandum No.
36012/22/93Estt.(SCT),dated 8.9.1993. It is also declared that I do not belong to
persons/sections(Creamylayer)mentionedinColumn3oftheScheduletotheabove
referred Office Memorandum, dated 8.9.1993, O.M. No. 36033/3/2004Estt.(Res),
dated9.3.2004and8.9.1993O.M.No.36033/3/2004Estt.(Res),dated14.10.2008.

NAME AND ADDRESS OF THE INSTITUTE/HOSPITAL

DISABILITY CERTIFICATE
Certificate No. ...............

Date ................................

Recent photograph of
the candidate showing
the disability duly
attested by the
Chairperson of the
Medical Board

This is certified that Shri/Smt./Kum ...........................................................

son/wife/daughter of Shri .................................... age .................sex ..................
identification marks (s) ........................................ is suffering from permanent disability of
following category:
A. Locomotor or cerebral palsy:
(i) BLBoth legs affected but not arms
(ii) BABoth arms affected

(a) Impaired reach

(b) Weakness of grip

(c) Ataxic
(iii) BLABoth legs and both arms affected
(iv) OLOne leg affected (right or left)

(a) Impaired reach

(b) Weakness of grip
(c) Ataxic

(v) OA- One arm affected

(a) Impaired reach

(d) Weakness of grip
(e) Ataxic

(vi) BHStiff back and hips (cannot sit or stoop)

(vii) MWMuscular weakness and limited physical endurance.
B.

Blindness or Low Vision :

(i) BBlind
(ii) PBPartially Blind

C.

Hearing Impairment :
(i) DDeaf
(ii) PDPartially Deaf

(Delete the category, whichever is not applicable)

2.

This condition is progressive/ non-progressive/ likely to improve/ not likely to improve.

Re-assessment of this case is not recommended/ is recommended after a period of

.................years ...................... months*.
3.

Percentage of disability in his/her case is ................................................ per cent.

4. Shri/Smt./Kum. ..................................................... meets the following physical requirements

for discharge of his/ her duties :
(i) FCan perform work by manipulating with fingers.

Yes/No

(ii) PPCan perform work by pulling and pushing.

Yes/No

(iii) LCan perform work by lifting.

Yes/No

(iv) KCCan perform work by kneeling and crouching.

Yes/No

(v) BCan perform work by bending.

Yes/No

(vi) SCan perform work by sitting.

Yes/No

(vii) STCan perform work by standing.

Yes/No

(viii) WCan perform work by walking.

Yes/No

(ix) SECan perform work by seeing.

Yes/No

(x) HCan perform work by hearing/speaking.

Yes/No

(xi) RWCan perform work by reading and writing.

Yes/No

(Dr. .............................)
Member
Medical Board

(Dr. ..................................)
Member
Medical Board

(Dr. ..............................)
Chairperson
Medical Board

Countersigned by the
Medical Superintendent/CMO/
Head of Hospital (with Seal)
*(Delete whichever is not applicable)