Annexure-I

Experience Certificate

Letter Head of the Institution/Issuing Authority

Telephone No…………
Email Id………
Name of Organization
Address of the Organization
Dated………..

This is to certify that Shri/Ms………S/o,D/o,W/o Shri……………was/is an employee of this

Organization/Department and duties performed by him/her during the period(s) are as under:

Name of From dd/mm/yy To Total Nature of Department/

post held dd/mm/yy period Appointment- Specially/Field
dd/mm/yy Regular/ of experience
Contract

(1) (2) (3) (4) (5) (6)

Pay scale Duties performed/experience gained in Place of posting Worked at

and last brief in each post(please give details, if supervisory
salary need be, in attached sheet)( in case of level/middle
drawn Medical posts, please mention field of management
specialization) level/head of
branch
(7) (8) (9) (10)

2. It is certified that above facts and figures are true and based on service records
available in our organization/Department.

Signature

Name of competent authority

Stamp of competent authority
 FORM SC/ST
FORM OF CERTIFICATE TO BE PRODUCED BY A
CANDIDATE BELONGING TO SCHEDULED CASTE OR
SCHEDULED TRIBE IN SUPPORT OF HIS / HER CLAIM.

[Link] is to certify that Sri / Smt / Kum* son

/ daughter* of of village / town*
in District / Division* of the State / Union
Territory* belongs to the _ Caste/Tribe* which is recognized as
a Scheduled Caste/ Scheduled Tribe* under :
* The Constitution ( Scheduled Castes) Order, 1950 ;
* The Constitution ( Scheduled Tribes) Order, 1950 ;
* The Constitution (Scheduled Castes)(Union Territories)Orders, 1951 ;
* The Constitution (Scheduled Tribes)(Union Territories)Order, 1951 ;

[as amended by the Scheduled Castes and Scheduled Tribes lists Modification) Order,1956; the Bombay
Reorganisation Act, 1960; the Punjab Reorganisation Act 1966, the State of Himachal Pradesh Act, 1970, the
North-Eastern Areas (Reorganisation)Act, 1971, the Constitution (Scheduled Castes and Scheduled Tribes)
Order (Amendment) Act,1976, The State of Mizoram Act, 1986, the State of Arunachal Pradesh Act, 1986 and
the Goa, Daman and Diu (Reorganization) Act, 1987.]:

* The Constitution (Jammu and Kashmir) Scheduled Castes Order,1956 ;

* The Constitution (Andaman and Nicobar Islands) Scheduled
Tribes Order, 1959 as amended by the Scheduled Castes and Scheduled
Tribes Orders (Amendment) Act, 1976 ;
* The Constitution (Dadra and Nagar Haveli) Scheduled Castes Order, 1962 ;
* The Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order, 1962 ;
* The Constitution (Pondicherry) Scheduled Castes Order 1964;
* The Constitution (Uttar Pradesh) Scheduled Tribes Order,1967;
* The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968 ;
* The Constitution (Goa, Daman and Diu) Scheduled Tribes Order, 1968 ;
* The Constitution (Nagaland) Scheduled Tribes Order, 1970 ;
* The Constitution (Sikkim) Scheduled Castes Order, 1978 ;
* The Constitution (Sikkim) Scheduled Tribes Order, 1978 ;
* The Constitution (Jammu and Kashmir) Scheduled Tribes Order, 1989 ;
* The Constitution (Scheduled Castes) Orders (Amendment)Act, 1990;
* The Constitution (ST) Orders (Amendment) Ordinance, 1991 ;
* The Constitution (ST) Orders (Second Amendment) Act,1991 ;
* The Constitution (ST) Orders (Amendment) Ordinance, 1996;
* The Scheduled Caste and Scheduled Tribes Orders (Amendment) Act 2002;
*The Constitution (Scheduled Castes) Order (Amendment) Act, 2002;
*The Constitution (Scheduled Caste and Scheduled Tribes) Order (Amendment) Act, 2002;
*The Constitution (Scheduled Caste) Order (Second Amendment) Act, 2002].

………2
 :: 2 ::

# 2. Applicable in the case of Scheduled Castes / Scheduled Tribes persons , who have migrated from one
State / Union Territory Administration.

This certificate is issued on the basis of the Scheduled Castes / Scheduled Tribes* Certificate issued to
Shri / Smt / Kumari* Father /Mother* of Sri / Smt /
Kumari* of village /
town in District/Division* of the State/Union
Territory* who belong to the Caste /
Tribe* which is recognized as a Scheduled Caste/Scheduled Tribe* in the State/Union Territory* issued
by the [Name of the authority] vide their order No.
dated .

[Link]/Smt/Kumari* and/or* his/her* family

ordinarily reside(s) in village/town* of District /
Division* of the State / Union Territory* of

Signature

Designation

Place: [With seal of Office]

Date : State/Union Territory

Note : The term "Ordinarily resides" used here will have the same meaning as in Section 20 of the
Representation of the Peoples Act, 1950.

* Please delete the words which are not applicable.

# Delete the paragraph which is not applicable.

List of authorities empowered to issue Caste / Tribe Certificates:

1. District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner / Additional Deputy
Commissioner / Deputy Collector/I Class Stipendiary Magistrate / Sub-Divisional Magistrate / Extra-Asst.
Commissioner / Taluka Magistrate / Executive Magistrate.

2. Chief Presidency Magistrate/ Additional Chief Presidency Magistrate / presidency Magistrate.

3. Revenue Officer not below the rank of Tehsildar.

4. Sub-Divisional Officers of the area where the candidate and / or his family normally resides.

Note: The Certificate is subject to amendment/modification of Scheduled Castes and Scheduled Tribes
lists from time to time as per Government of India Guidelines.
-- -- --
 FORM OBC
FORM OF CERTIFICATE TO BE PRODUCED BY
OTHER BACKWARD CLASSES APPLYING FOR APPOINTMENT
TO POSTS UNDER THE GOVERNMENT OF INDIA

This is to certify that Sri / Smt. / Kumari son/daughter of

of village/Town District/Division
in the State/ Union Territory belongs to the
community which is recognized as a backward class under the Government of
India, Ministry of Social Justice and Empowerment’s Resolution No. dated *.
Shri/Smt./Kumari and/or his/her family ordinarily reside(s) in the
District/Division of the State/Union Territory. 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 OM No.36012/22/93- Estt.[SCT],
dated 8-9-1993 **.

Dated : District Magistrate

Deputy Commissioner etc.

Seal

* - the authority issuing the certificate may have to mention the details of Resolution of
Government of India, in which the caste of the candidate is mentioned as OBC.
**- As amended from time to time.
Note:- The term “Ordinarily” used here will have the same meaning as in Section 20 of the
Representation of the People Act, 1950.
The Prescribed proforma shall be subject to amendment from time to time as per Government of India
Guidelines.
 FORM EWS
Government of ………………………..
(Name & Address of the authority issuing the certificate)
INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS
(Prescribed proforma subject to amendment from time to time)
Certificate No. …………
Date : …………

VALID FOR THE YEAR …………

This is to certify that Shri/Smt./Kumari ………….. son/daughter/wife of ........................ permanent resident of
……………………….. ViIlage/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/her family** is below Rs. 8 lakh (Rupees Eight Lakh only) for the
financial year His/her family does not own or possess any of the following assets*** :

I. 5 acres of agricultural land and above;

II. Residential flat of 1000 sq. ft. and above;
III. Residential plot of 100 sq. yards and above in notified municipalities;
IV. Residential plot of 200 sq. yards and above in. areas 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 (Central List)

Signature with seal of Office …………

Name …………

Designation …………
Recent Passport
size
attested
photograph
of the applicant

* Note 1: Income covered all sources i.e. salary, agriculture, business, profession, etc.
**Note 2 :The term 'Family" for this purpose include the person, who seeks benefit 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.
***Note 3 : The property held by a "Family' in different locations or different places/cities have been clubbed while
applying the land or property holding test to determine EWS status.
NOTE :- The Income and Asset Certificate issued 'by anyone of the following authorities in the prescribed format
as given above shall only be accepted as proof of candidate's claim as 'belonging to EWS : -
(i) District Magistrate/Additional District Magistrate/ Collector/ Deputy Commissioner/Additional Deputy
Commissioner/1st Class Stipendiary Magistrate/ Sub-Divisional Magistrate/ Taluka Magistrate/ Executive Magistrate/
Extra Assistant Commissioner,
(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/ Presidency Magistrate,
(iii)Revenue Officer not below the rank of Tehsildar and
(iv) Sub-Divisional Officer or the area where the candidate and/or his family normally resides.
 FORM-I
Certificate of Disability
(In cases of amputation or complete permanent paralysis of limbs or dwarfism and in cases of
blindness) (Prescribed proforma subject to amendment from time to
time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent passport
size attested
photograph
(Showing face
only) of the
person with
disability

Certificate No. : Date :

This is to certify that I have carefully examined

Shri/Smt./Kum. son/wife/daughter of Shri

Date of Birth (DD /
MM / YY) Age years, male/female
registration No. permanent
resident of House No. Ward/Village/Street Post Office

District State , whose photograph is affixed

above, and am satisfied that :

(A) he/she is a case of :

 locomotor disability
 Dwarfism
 Blindness
(Please tick as applicable)
(B) The diagnosis in his/her case is
(A) He/She has % (in figure) percent (in words) permanent
locomotor disability/ dwarfism /blindness in relation to his/her (part of body) as per guidelines (
.................... number and date of issue of the guidelines to be specified)
2. The applicant has submitted the following documents as proof of residence :-
Nature of Date of Issue Details of authority issuing certificate
Document

(Signature and Seal of Authorised Signatory of notified Medical Authority)

Signature/Thumb
impression of the
person in whose
favour disability
certificate is issued.
 FORM - II
Certificate of Disability
(In case of multiple disabilities)
(Prescribed proforma subject to amendment from time to time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent PP size
Attested
Photograph
(Showing face
only) of the person
with disability

Certificate No. : Date :

This is to certify that we have carefully examined

Shri/Smt./Kum. son/wife/daughter of Shri

Date of Birth (DD / MM / YY)
Age years, male/female registration No. permanent
resident of House No. Ward/Village/Street Post Office

District State , whose photograph is affixed

above, and am satisfied that :

(A) He/she is a Case of Multiple Disability. His/her extent of permanent physical impairment/disability has
been evaluated as per guidelines (( ................... number and date of issue of the guidelines to be specified)
for the disabilities ticked below, and is shown against the relevant disability in the table below :
Sr. Disability Affected Diagnosis Permanent physical
No. Part of impairment/mental disability
Body (in %)
1 Locomotor disability @
2 Muscular Dystrophy
3 Leprosy cured
4 Dwarfism
5 Cerebral Palsy
6 Acid Attack Victim
7 Low vision #
8 Blindness #
9 Deaf £
10 Hard of Hearing £
11 Speech and Language
Disability
12 Intellectual Disability
13 Specific Learning
Disability
14 Autism Spectrum disorder
15 Mental-illness
16 Chronic Neurological
Conditions
17 Multiple sclerosis
18 Parkinson’s disease
19 Haemophilia
20 Thalassemia
21 Sickle Cell disease
(B) In the light of the above, his/her over all permanent physical impairment as per guidelines
( ................... number and date of issue of the guidelines to be specified), is as follows :-

In figures :- percent

In words :- percent

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

3. Reassessment of disability is :

(i) not necessary,

Or

(ii) is recommended / after years months, and therefore this certificate shall be valid till
(DD / MM / YY)

@ - e.g. Left/Right/both arms/legs

# - e.g. Single eye

£ - e.g. Left / Right / both ears

4. The applicant has submitted the following documents as proof of residence :-

Nature of Date of Details of authority issuing certificate

Document Issue

5. Signature and Seal of the Medical Authority

Name and seal of Member Name and seal of Name and seal of Chairperson
Member

Signature/Thumb
impression of the
person in whose
favour disability
certificate is
issued.
 FORM - III
Certificate of Disability
(In cases other than those mentioned in Form I and II)
(Prescribed proforma subject to amendment from time to time)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent
passport size
Attested
Photograph
(Showing face
only) of the
person with
disability

Certificate No. : Date :

This is to certify that I have carefully examined

Shri/Smt./Kum.
son/wife/daughter of Shri Date of Birth (DD /
MM / YY)
Age years, male/female Registration No. permanent
resident of House No. Ward/Village/Street
Post Office
................... District State , whose photograph is
affixed above, and am satisfied that he/she is a Case of disability. His/her
extent of percentage physical impairment/disability has been evaluated as per guidelines (
.................... number and date of issue of the guidelines to be specified) and is shown against the relevant
disability in the table below:

Sr. Disability Affected Diagnosis Permanent physical

No. Part of impairment/mental
Body disability (in %)
1 Locomotor disability @
2 Muscular Dystrophy
3 Leprosy cured
4 Cerebral Palsy
5 Acid Attack Victim
6 Low vision #
7 Deaf €
8 Hard of Hearing €
9 Speech and Language Disability

10 Intellectual Disability
11 Specific Learning Disability

12 Autism Spectrum disorder

13 Mental-illness
14 Chronic Neurological
Conditions
15 Multiple sclerosis
16 Parkinson’s disease
17 Haemophilia
 18 Thalassemia
19 Sickle Cell disease
(Please strike out the disabilities which are not applicable.)

2. The above condition is progressive/non-progressive/likely to improve/not likely to improve.

3. Reassessment of disability is:

(i) not necessary,

Or

(ii) is recommended / after years months, and therefore this certificate shall be valid till
(DD / MM / YY)

@ - e.g. Left/Right/both arms/legs

# - e.g. Single eye / both eyes

£ - e.g. Left / Right / both ears

4. The applicant has submitted the following documents as proof of residence:-

Nature of Date of Details of authority issuing certificate

Document Issue

(Authorised Signatory of notified Medical Authority)

(Name and Seal)
Countersigned
{Countersignature and seal of the
CMO/Medical Superintendent/Head of
Government Hospital, in case the
certificate is issued by a medical
authority who is not a government
servant (with seal)}

Signature/Thumb
impression of the
person in whose
favour disability
certificate is
issued.