Application form for SC/ST/OBC

			
				Government of West Bengal
Backward Classes Welfare Department
Application form for SC/ST/OBC Certificate

1. Application to:

State*
WEST BENGAL

District*

Sub-division *

Municipality

Block

Police Station

*

2. Applying for:

SC ST OBC

Caste/Tribe/Community: *

3. Name: *

4. Father's name: *

5. Mobile No.:

6. Email ID:

7. Documents Required ( At least One):*

(a) Epic No.:

(b) Aadhaar No.:

(c) Khadya sathi No.:

8.(a) Date of Birth: *

(b) Place of Birth: *

9. Address:

a) Present Address for last 6 months:
C/O (Name):
State:	*
District:
Police Station:	*
Ward/GP:	*
Vill/Para/House No./Road:	*
Post Office:	*
Pin Code :

b) Permanent Address: *Same as present? Yes No*
C/O (Name):
State:	*
District:	*
Police Station:	*
Ward/GP:	*
Vill/Para/House No./Road:	*
Post Office:	*
Pin Code :
Any more? YES NO

c) Other address :			C/O (Name):
Para/House/Village:*	Ward No./G.P. :*	Post Office:*	Police Station :*	District:*	State:*	Pin :

10. Nationality:

INDIAN

11. Religion:

*

12. Gender:

*

13. Blood relation (paternal side) details: *Yes* No
a) Certificate holder's name:		*
b) Relation with applicant:		*

c) Certificate No: *	d) Date of issue: *
e) Issuing authority:		*

14. Details of two(2) local referees:
a) Name of Referee-I:	*
b) Address of Referee-I:	*
c) Name of Referee-II:	*
d) Address of Referee-II:	*

15. Whether the applicant or his family migrated from other State/Country? Yes No

Migration Certificate No:			Date of issue:
Country	State	District	Police Station	Village/Ward	Year of migration *