APPLICATION FORM
SCHEDULED CASTE CLASS/SCHEDULED TRIBE CLASS/

BACKWARD CLASS FOR

PROFORMA

Affix 2 Rupees
Court Fee Stamp
To
Khairtabad Mandal,
HYDERABAD, A.P.
Sir,
1. Name of the Applicant
    (in Block Letters & Full)		 :__________________________________________________________
2. Father's Name :__________________________________________________________
3.Sex :__________________________________________________________
4. Native Place
    (Origin District)		 :__________________________________________________________
5. Present Address H.No. :__________________________________________________________
6. Caste Claimed
     S.C./S.T./B.C./O.C.		 :__________________________________________________________
7. List of Documents enclosed T.C. from the
     recognised School or College of Caste
    certificate earlier if any to the family member		 :__________________________________________________________
8. Oritin of present Age
    Affidavit duly enclosed		 :__________________________________________________________
9. Copy of the Ration Card :__________________________________________________________
10. Two different Gazetted Officer's Certificate of
        State Government		 :__________________________________________________________

DECLARATION
                I declare that the information furnished by me in this application is true and correct and that it is found to be
untrue and incorrect, I will be liable for prosecution for furnishing false information under Section 199 and 200 of I.P.C.
 Date:                         /                           /

SIGNATURE OF THE APPLICANT
Certificates enclosed:  (          )
1) Two different State Govt. Gazetted Officers Certificate
2) Affidavit with Notary on Rs.10/- Bond Paper
3) T.C. or Bonafides Xerox with attested by the Gazetted Officer
4) Ration Card with Attested by the Gazetted Officer
5) Photo Identity Card issued by the Election Commission or Electorate rolls from Municipality
6) Caste Certificate issued to any of the family members xerox attested by the Gazetted Officer
7) Certificate from the Registered Caste Sangham xerox attested  by the Gazetted  Officer