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SC/ST Certificate Application Form

1. Ranjan Bagdi is applying for a Scheduled Caste certificate as he belongs to the Bagdi caste. 2. He provides details such as his name, father's name, date and place of birth, current and permanent addresses, nationality, religion, sex, Aadhar number, and contact details of two referees. 3. He confirms that his family has always lived in West Bengal and has not migrated from another state or country.

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BIVAS MAHATA
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38 views1 page

SC/ST Certificate Application Form

1. Ranjan Bagdi is applying for a Scheduled Caste certificate as he belongs to the Bagdi caste. 2. He provides details such as his name, father's name, date and place of birth, current and permanent addresses, nationality, religion, sex, Aadhar number, and contact details of two referees. 3. He confirms that his family has always lived in West Bengal and has not migrated from another state or country.

Uploaded by

BIVAS MAHATA
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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,
Khatra , Bankura.
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 : SCWB13032021/49162 ( Block : RANIBANDH )
1. (a) Applying for : SC (b) Name of caste : BAGDI
2. Full Name of Applicant : RANJAN BAGDI
5. Contact No. :
3. Father's Name : MADHU BAGDI
6. Email Id. :
4. (a) Date of Birth : 14/06/1995
(b) Place of Birth : 7. Adhar No. :

Village / Ward Police Station District State


RUDRA RANIBANDH BANKURA WEST BENGAL

8. Address since birth :


(a) Present address :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
RUDRA RUDRA RUDRA BANKURA WEST 722135
BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN

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
SAYEN BAGDI REAL SISTER WB1303SC2021046475 27/09/2021 Khatra

13. Details of two(2) referees:


Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
MADHU BAGDI RUDRA,RUDRA,RANIBANDH DULAL BAGDI RUDRA,RUDRA,RANIBANDH,

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 )

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