ANNEXURE C

SCHEDULED TRIBES CANDIDATES

This is to certify that Shri/Shrimati/Kumari*__________________________ son/daughter*of__________________________of village/Town*___________________ in District/ Division* Shri___________________________ of State/Union Territory* _______________________belongs to the__________________________ Caste/Tribe* which is recognised 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) Order, 1951* The Constitution (Scheduled Tribes) (Union Territories) Order, 1951*_____

[as amended by the Scheduled Castes and Scheduled Tribes Lists (Modification) Order, 1956, the Bombay Recognisation Act, 1960, the Punjab Recognisation Act,1966, the State of Himachal Pradesh Act, 1970 and the North Eastern Areas (Recognisation) Act, 1971 and the Scheduled Castes and Scheduled Tribes Orders,(Amendment) Act, 1976]

The Constitution (Jammu & Kashmir Scheduled Castes Order, 1956*

The Constitution (Andaman and Nicobar Islands ) Scheduled Tribes Order, 1959* as amended by the Scheduled Castes and Scheduled Tribes Order (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 Orders,1964*

The Constitution (Scheduled Tribes)(Uttar Pradesh) Order, 1967*

TheConstiution (Goa, Daman and Diu) Scheduled Castes Order,1968*

TheConstiution (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*

2. Shri/Shrimati/Kumari*____________________and/or his/her* family, reside(s) in village/town*___________________ of* _____________________ District/Division* of the State/Union Territory* of ___________________.

Signature_____________________

** Designation___________________

(with seal of Office)

State/Union Territory**

Place__________________

Date __________________

*Please delete the words which are not applicable.

Note: The term "ordinarily reside(s)** used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.

**Officers competent to issue Caste/Tribe certificates:

1. District Magistrate/Additional District Magistrate/Collector/Deputy Commission/Additional Deputy Commissioner/Deputy Collector/Ist Class Stipendiary Magistrate/City Magistrate/Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner.
2. (not below the rank of Ist class Stipendary Magistrate)
3. Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency Magistrate.
4. Revenue Officers not below the rank of Tehsildar.
5. Sub-Divisional Officer of the area where the candidate and/ or his family normally reside(s).
6. Administrator/Secretary to Administrator/Development Officer (Lakshdweep).

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES

This is to certifiy ____________________S/O_____________________ of Village __________________ District/Division*___________________ in the _______________state belongs to the______________Community which is recognised as a Backward Class under:-

Government of India, Ministry of Welfare `Resolution No. 12011/68/93-BCC (C) dated 10^th September, 1993 published in the Gazette of India Extraordinary Part-I Section-1 dated the 13^th September, 1993. **
Government of India, Ministry of Welfare Resolution No. 12011/9/94-BCC dated 19.10.1994 published in the Gazette of India Extraordinary Part-I, Section-1, No. 163 dated 20.10.1994.

Shri_______________________________and/or his family ordinary reside(s) in the____________________District/Division of the___________________State.
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 and Training O.M. No. 36002/22/93-Estt. (SCT) dated 8.9.93.

Deputy Magistrate
Deputy Commissioner etc.

Dated:
SEAL:

N.B.:-(a) The term `Ordinarily' used here will have the same meaning as in the Section 20 of the Representation of the People's Act, 1950.

(b) Where the certificates are issued by the Gazetted Officer of the Union Government or State Governments, they should be in the same form but countersigned by the District magistrate of Deputy Commissioner (Certificates issued by Gazetted Officers and attested by the District Magistrate/Deputy Commissioner are not sufficient).
* Strike out whichever is not applicable.
** Officers Competent to issue Class/Tribe Certificates.

(i) District Magistrate/Additional District Magistrate/Collector/Deputy Commission/Additional Deputy Commissioner/Deputy Collector/Ist Class Stipendiary Magistrate/City Magistrate/Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner.
(not below the rank of Ist class Stipendary Magistrate)

(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/ Presidency Magistrate.

(iii) Revenue Officers not below the rank of Tehsildar.

(iv) Sub-Divisional Officer of the area where the candidate and/ or his family normally reside(s).

(v)Administrator/Secretary to Administrator/Development Officer (Lakshdweep).

FORM FOR PHYSICALLY DISABLED CATEGORY

I, Dr. _________________________ Regn. No. _______________ examined Shri/Smt./Kum. ____________________ whose particulars are given below and hereby certify that he/she is a permanent physically disabled person of the following category:-

(i)

BL-Both Legs affected but not arms.

(ii)

BA-Both arms affected

(a) Impaired reach
(b) Weakness of grip

(iii)

BLA-Both legs and both arms affected

(iv)

OL-One leg affected (right or left)

(a) Impaired reach
(b) Weakness of grip
(c) Ataxic

(v)

OA-One arm affected

(a) Impaired reach
(b) Weakness of grip
(c) Ataxic

(vi)

BH-Stiff back and hips (Cannot sit or stoop)

(vii)

MW-Muscular weakness and limited physical endurance

(viii)

B-Blind

(ix)

PD-Partially Deaf

(x)

D-Deaf

(Delete the category whichever is not applicable)

2. The percentage of disability in hi/her case is ___________________.

3. Shri/Smt/Kum _______________ meets the following physical requirement for discharge of his/her duties:-

(i)

F-Work performed by manipulating with fingers.

(ii)

PP-Work performed by pulling and pushing

(iii)

L-Work performed by lifting

(iv)

KC-Work performed by kneeling and chrouching.

(v)

B-Work performed by bending

(vi)

S-Work performed by sitting

(vii)

ST-Work performed by standing

(viii)

W-Work performed by walking

(ix)

SE-Work performed by seeing

(x)

H-Work performed by hearing/speaking

(xi)

RW-Work performed by reading and writing

(Delete whichever is not applicable)

4. Shri/Smt/Kum ___________ does not suffer from disease (communicable or otherwise), constitutional weakness or bodily infirmity that may interfere with the efficient discharge of his/her duties as an Officer under the Govt. of India.

    (i)    Name of the Candidate ______________________________
    (ii)    Father's Name            _______________________________
    (iii)    Indentification Marks   _______________________________
    (iv)    Sex                            ______________________________
    (v)    Age                            ______________________________

Signature of Surgeon/Medical Officer
Designation________________

Signature of Candidate

Office Stamp ________________
Address ____________________

Note: The disability certificate should be issued by a Govt. Hospital

(i)	BL-Both Legs affected but not arms.
(ii)	BA-Both arms affected	(a) Impaired reach (b) Weakness of grip
(iii)	BLA-Both legs and both arms affected
(iv)	OL-One leg affected (right or left)	(a) Impaired reach (b) Weakness of grip (c) Ataxic
(v)	OA-One arm affected	(a) Impaired reach (b) Weakness of grip (c) Ataxic
(vi)	BH-Stiff back and hips (Cannot sit or stoop)
(vii)	MW-Muscular weakness and limited physical endurance
(viii)	B-Blind
(ix)	PD-Partially Deaf
(x)	D-Deaf
(Delete the category whichever is not applicable)

(i)	F-Work performed by manipulating with fingers.
(ii)	PP-Work performed by pulling and pushing
(iii)	L-Work performed by lifting
(iv)	KC-Work performed by kneeling and chrouching.
(v)	B-Work performed by bending
(vi)	S-Work performed by sitting
(vii)	ST-Work performed by standing
(viii)	W-Work performed by walking
(ix)	SE-Work performed by seeing
(x)	H-Work performed by hearing/speaking
(xi)	RW-Work performed by reading and writing
(Delete whichever is not applicable)