Annexure I

Paste recent
Format of application
passport size
photo duly
Advertisement No. WSCM/01/2025 …………………………………………… attested by the
applicant.
1. Name of the post applied for ……………………………………………..………

2. Name of the Candidate (In Block Letters)

3. Father’s/Husband’s Name

4. Employment Exchange Card No, if any ……………………………………………………

5. Correspondence Address with Phone No.

P I N
S T A T E
M O B I L E N O
E mail

6. Permanent address:

P I N
S T A T E

7. Nationality ……………………………………………………………………

8. Category (SC/ST/OBC/EWS/PH/Others)……………………………………………

9. Date of Birth
(a) In figures
D D M M Y Y Y Y

(b) In Words …………………………………………………………………

10. Gender ……………………………………………………………………………

11. Education/Professional Qualification possessed/examination passed (duly supported by
certificates)

Name of the Subjects Name of the Regular/ Date of Percentage

Examination Institute/Board/University Correspondence declaration
Passed of result

12. Work Experience (If any) (in chronological order) duly supported by experience certificates in
the prescribed format.

S. Name & full Govt./Semi Designation Nature of Salary From To Duration of

No. address of Govt./ duties drawn Service
Institution/ Private performed Y M D
Establishment

DECLARATION
I do hereby declare that the following information furnished in the format towards support of my age,
educational qualification, experience, category and other particulars in connection with my candidature for the
post of ………………………………………………..…………… in any WSCs falling under West Zone is true
and correct to the best of my knowledge and belief. In case, any information found false or incorrect in future,
my candidature is liable to be treated as cancelled and my employment terminated forthwith.

Place:
Signature of the candidate
Date:

List of copies of documents enclosed

1. _________________________________

2. _________________________________

3. _________________________________

4. _________________________________

5. _________________________________
 Annexure-II

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES

APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA

[Govt. of India, Department of Per &Trg. OM No.36033/28/94-Estt(Res)dated 02.07.1997]

This is to certify that______________________________________________

son/daughterof_____________________________________Vill.___________________________
______________________District/Division_____________________________ in the
_______________State belongs to the ____________________ community which is recognized as
a backward class under:-

(i) Government of India, Min of Welfare, Resolution No.12011/68/93-BCC© dated the

10 September 1993 published in the Gazette of India, Extraordinary, Part I, section-
1, No.186 dated the 13th September 1993.
(ii) Government of India, Min of welfare, Resolution No. 12011/9/94-BCC dated the
19th Oct. 1994, published in the Gazette of India, Extraordinary, Part-1, section
No.163, dated the 20th October, 1994.
(iii) Government of India, Min of Welfare, Resolution no.12011/7/95-BCC dated the 24th
May 1995, published in the Gazette of India, Extraordinary, Part-1, section1, No.88,
dated the 25h May 1995.
(iv) Government of India, Min of Welfare, Resolution No.12011/44/96-BCC dated the
6th December 1996, published in the Gazette of India, Extraordinary, Part-1 Section-
1, No.210, dated the 11th December 1996.

Shri_____________________and or his family ordinary resides in the

____________ District/Division____________ State. This is to also 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, OM
No.36012/22/93-Estt(SCT) dated 08.09.1993.

Dated:

Seal District Magistrate/

Deputy Commissioner etc.
 Annexure-III

(FORMAT OF THE CERTIFICATE TO BE PRODUCED BY SCHEDULED CASTES AND SCHEDULED

TRIBES CANDIDATES APPLYING FOR APPOINTMENT TO POST UNDER THE GOVERNMENT OF INDIA)

This is to certify that Shri/Shrimati/Kumari* _________________________________

son/daughter of _______________________of village/town* on District/Division
*______________________________ of the State/Union Territory* ____________Belongs to the
Caste/Tribes*_______________ which is recognized as a Scheduled Castes/Scheduled Tribes*
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 Reorganization Act, 1960 & the Punjab Reorganization Act, 1966, the State of Himachal
Pradesh Act 1970, the North-Eastern Area(Reorganization) Act, 1971 and the Scheduled Castes and
Scheduled Tribes Order(Amendment) Act, 1976.
The Constitution (Jammu & Kashmir) Scheduled Casted order,
1956__________________________________
The Constitution (Andaman and Nicobar Islands) Scheduled Tribes order, 1959 as amended by the
Scheulded Casted 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 order, 1964@
The Constitution (Scheduled Tribes) (Uttar Pradesh) order, 1967@
The Constitution (Goa, Daman & Diu) Scheduled Castes order, 1968@
The Constitution (Goa, Daman & 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 & Kashmir) Scheduled Tribes order, 1989@
The Constitution (SC) orders (Amendment) Act, 1990@
The Constitution (ST) orders (Amendment) Ordinance 1991@
The Constitution (ST) orders (Second Amendment) Act, 1991@
The Constitution (SC) orders (Amendment) Ordinance, 1996
%2.Application 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/ Shrimati___________________Father/ Mother________________ of Shri/ Shrimati/
Kumari* ___________________________ of village/ town*_______________________ in
District/ Division* ___________________________ of the State/ Union Territory*
__________________________ who belong to the __________________ Caste/ Tribes which is
recognized as a Scheduled Casted/Scheduled Tribe in the State/Union Territory issued by the
_______________ dated _____________________ %3.Shri/ Shrimati/ Kumari and or* his/her
family ordinarily reside(s) in village/town*______________________ of _______________
District/ Division*___________of the State/Union Territory of ___________________

Place ________________
Signature_______________
Date_________________
Designation______________
(with seal of office)
*Please delete the words which are not applicable.
@Delete quote specific presidential order.
% Delete the paragraph which in not applicable.
NOTE: The term ordinary reside(s) used here will have the meaning as in section 20 of the
Representation of the people Act, 1950.
** List of authorities empowered to issue Caste/Tribe Certificate:
(i) District Magistrate/Additional District Magistrate/Collector/Deputy
Commissioner/Additional Deputy Commissioner/Dy. Collector/1st Class Stipendiary
Magistrate/Sub-Divisional Magistrate/Extra-Assistant Commissioner/Taluka
Magistrate/Executive Magistrate.
(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency
Magistrate.
(iii) Revenue officers not below the rank of Tehsildar.
(iv) Sub- Divisional Officers of the area where the candidate and/or his family normally
resides.\

NOTE: ST candidates belonging to Tamil Nadu state should submit caste certificate ONLY FROM
THE REVENUE DIVISIONAL OFFICER.
 Annexure-IV

Government of …………..
(Name & Address of the authority issuing the certificate)

INCOME & ASSEST CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER

SECTIONS

Certificate No. Date:

VALID FOR THE YEAR ______________

This is to certify that Shri/Smt./Kumari ______________________________________________

son/daughter/
wife of ____________________ permanent resident of
____________________________________________, Village /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 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

_____________ casts 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.
 Annexure-V

The form of Certificate to be produced by Government servants for claiming Age concession

(Letter Head of the Institution/Issuing Authority)

This is to certify that Shri/Ms…………………………………………………., S/o,D/o,W/o

Shri………………………………. is a regularly appointed an employee of this Organization/

Department/Ministry and duties performed by him/her during the period (so are as under:-

Certified That:

(a)Shri/Smt/Kum ………………………………………………………… holds substantively a

permanent post of ……………………………………………………………………………. in the
Office/ Department of …....…….……………………………………………………… with effect
from ………………………………………………

(b)Shri/Smt/Kum……………………………………………………… has been continuously in

temporary service on a regular basis under the Government in the post of
...……………………………………………………………………………………….. in the Office/
Department ………………………………… with effect from …………………………

Signature……………………………

Name………………………………..

Designation…………………………

Ministry/Office…………………….

Address…………………………….

Office SEAL………………………
Place:

Date:

*Strike out whichever is not applicable.

 Annexure-VI

EXPERIENCE CERTIFICATE

(The form of certificate to be produced by candidates for claiming experience)

Letter Head of the Institution/Issuing Authority

Name of Organisation

Address of the Organisation Dated ………

This is to certify that Shri/Ms…………………………………..S/o, D/o, W/o Shri …………

was/is an employee of this Organisation/Department/Ministry and duties performed by him/her
during the period(s) are as under:

Nam From To Total Nature of Department/Specialty/Fiel

e of dd/mm/y dd/mm/y period Appointment/Permanent d of Experience
Post y y dd/mm/y /
head y Regular/Temporary/Part
time/Guest/Honorary
etc.
1 2 3 4 5 6

Pay Scale & Last Duties performed/Experience gained in brief in Place of posting
Salary Drawn each post(please give details. If need be, in
attached sheet duly signed with seal
7 8 9

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

Signature………………

Name of Competent Authority………………………

Stamp of Competent Authority……………………..