Meeseva Revenue Integrated BC-E Application form
To
The Tahsildar
.............................
............................District.
Sir
I am in need of Backward Class Community Certificat
e for my Son/Daughter/
.................................................... For which the details are give below.
1. Name of the Applicant in full (in Block Letters):
2. Sex of the Applicant :
3. a) Father’s Name :
b) Mother’s Name :
4. Present Postal Address :
D.No: Locality:
Village: Mandal:
District: Pincode:
5. Permanent Place of Residence :
D.No: Locality:
Village: Mandal:
District: Pincode:
6. Age, Date of Birth and Place of Birth (if date is not known approx, Year of Birth) :
7. Place of ordinary Residence Documents related
to house/Land or other immovable property or
Birth Registration Certificates or Ration Card or
School records may be furnished :
8. If the applicant has been issued a Community
Certificate in the past by any authority, a copy
of such Certificate should be furnished. :
9. Community for which certificate is claimed
(including Group, Sub-Group) :
10. Religion professed by the father of the
Applicant :
11. (a) Religion professed by the Father of the
Applicant :
(b) Religion professed by the mother of the
Applicant:
12. Ration card Number :
13. Aadhaar Number :
14. Mobile :
15. Phone :
16. Email:
(PTO) ::
17 (a) Class/Community/ Group (including sub-group)of the father__________________
(b) Class/ Community Group(including sub-group) of the father___________________
18. if to be included under other Muslim groups under Item No.15 of G.O.Ms,. No.23 Backward
Classes Welfare (C2) Department, dated 7th July, 2007.
I hereby declare that I belongs to other Muslim gro
ups excluding Syed, Saiyed, Sayyed,
Mushaik, Mughal, Moghal; Pathans: Iranl; Arab; Bohare:
Bohara: Shia Imami ismail, Khoja,
Cutchi-Memon; Jamayat; Navayat, and all the synonyms
and sub-groups of the excluded groups;
and except those who have been already included in
the State list of Backward Classes.
19. Whether the Applicant is
(a)A natural born Son/Daughter of his/her parents
____________________________
OR
(b)Not
DECLARATION
I/We declare that the information furnished by me /
us in the application is true and correct, and
the documents appended thereto are genuine and the
contents of the documents are true and
correct and that if these are found to be untrue an
d incorrect, I/We will be liable for prosecution
for furnishing false and incorrect information/ doc
uments under section 10 of the Act No.16 of
1993.
Station:
Signature of the
Applicant.
Date :
Signature of the Parent/Guardian
Enclosures:
1. Application Form*
2. Caste Certificate issued to the family members#
3. SSC marks memo or DOB extract or Transfer certificate#
4. 1 TO 10th study certificate or DOB certificates
issued by Municipality/Gram Panchayath#
5. Ration Card/EPIC Card /AADHAR CARD#
6. Schedule I to IV #
(*-mandatory #-any one of them)
To
The Tahsildar
.............................
............................District.
Sir
I am in need of Backward Class Community Certificat
e for my Son/Daughter/
.................................................... For which the details are give below.
1. Name of the Applicant in full (in Block Letters):
2. Sex of the Applicant :
3. a) Father’s Name :
b) Mother’s Name :
4. Present Postal Address :
D.No: Locality:
Village: Mandal:
District: Pincode:
5. Permanent Place of Residence :
D.No: Locality:
Village: Mandal:
District: Pincode:
6. Age, Date of Birth and Place of Birth (if date is not known approx, Year of Birth) :
7. Place of ordinary Residence Documents related
to house/Land or other immovable property or
Birth Registration Certificates or Ration Card or
School records may be furnished :
8. If the applicant has been issued a Community
Certificate in the past by any authority, a copy
of such Certificate should be furnished. :
9. Community for which certificate is claimed
(including Group, Sub-Group) :
10. Religion professed by the father of the
Applicant :
11. (a) Religion professed by the Father of the
Applicant :
(b) Religion professed by the mother of the
Applicant:
12. Ration card Number :
13. Aadhaar Number :
14. Mobile :
15. Phone :
16. Email:
(PTO) ::
17 (a) Class/Community/ Group (including sub-group)of the father__________________
(b) Class/ Community Group(including sub-group) of the father___________________
18. if to be included under other Muslim groups under Item No.15 of G.O.Ms,. No.23 Backward
Classes Welfare (C2) Department, dated 7th July, 2007.
I hereby declare that I belongs to other Muslim gro
ups excluding Syed, Saiyed, Sayyed,
Mushaik, Mughal, Moghal; Pathans: Iranl; Arab; Bohare:
Bohara: Shia Imami ismail, Khoja,
Cutchi-Memon; Jamayat; Navayat, and all the synonyms
and sub-groups of the excluded groups;
and except those who have been already included in
the State list of Backward Classes.
19. Whether the Applicant is
(a)A natural born Son/Daughter of his/her parents
____________________________
OR
(b)Not
DECLARATION
I/We declare that the information furnished by me /
us in the application is true and correct, and
the documents appended thereto are genuine and the
contents of the documents are true and
correct and that if these are found to be untrue an
d incorrect, I/We will be liable for prosecution
for furnishing false and incorrect information/ doc
uments under section 10 of the Act No.16 of
1993.
Station:
Signature of the
Applicant.
Date :
Signature of the Parent/Guardian
Enclosures:
1. Application Form*
2. Caste Certificate issued to the family members#
3. SSC marks memo or DOB extract or Transfer certificate#
4. 1 TO 10th study certificate or DOB certificates
issued by Municipality/Gram Panchayath#
5. Ration Card/EPIC Card /AADHAR CARD#
6. Schedule I to IV #
(*-mandatory #-any one of them)