No.1-TLR/OBC/2006-07/ 2'3 ~ ~ OFFICE OF THE DEPUTY COMMISSIONER ANDAMANS DISTRICT ******* Port Blair, dated the 5th May, 2006 PRESS NOTE Eligible persons covered under Other Backward Classes of the Andaman & Nicobar Islands viz. The Pre-1942 Settlers of Andaman & Nicobar Islands comprising of the (1) Local Borns (2) The Bhatus or The Bhantus (3) The Moplahs and (4) The Karens and Post-1942 Bengali Settlers settled in the islands under various rehabilitation schemes of the Central Government, as notified in the Official Gazette vide No.343j2005jF.No.8-3j2003-TW dated 16th December 2005 and subsequent corrigendum published in the Official Gazette vide No.75j2006jF.No.8-3j2003-TW dated 19th April, 2006 are hereby required to apply in the prescribed format as annexed for issuance Other Backward Classes Certificate. The format is also available on the Administration's website www.and.nic.in. The applications are to be filed with necessary documents with the offices of concerned Tehsildars. Mr;A~ Assistant ~bmmi~ner (HQ) For Deputy CommIssioner (A) APPLICATION FORM FOR ISSUING OF OTHER BACKWARD CLASSES (OBC) CERTIFICATE IN ANDAMAN & NICOBAR ISLANDS No. To, Affix your The Tehsildar photo Here (Passport size) ................ Sir, I request that a Certificate in respect of reservation for Other Backward Classes in A & N Islands may kindly be granted to me. I give below the necessary particulars: (in BLOCK letters) 2. Complete Residential Address (a)Present............................... ................................ ................................ .............. ............................... ................................ ................................ .............. (b)Permanent............................... ................................ ................................ ......... ............................... ................................ ................................ .............. Enclose attested residential poof as a bonafide Permanent resident of A & N Islands i.e, (I) Islanders Identity Card and (II) Local Certificate under category 1a(i)(ii)&(iii), 1b(i)&(ii) 3. Islanders Identity Card No 4. Date of Birth Age Proof Birth Certificate / Matriculation Certificate/ School Leaving Certificate 5. Religion 6. Occupational Group a) Student b) Service c) Business d) Agriculture e) Others (to be specified) Please tick . which ever is applicable. 7. Community a) Local Borns (Belonging to Pre-1942) b) Bathus ( Belonging to Pre-1942) c) Moplas ( Belonging to Pre-1942) d) Karens ( Belonging to Pre-1942) e) Bengali Settlers -( Post 1942 Bengali Settlers settled in the Islands under various rehabilitation schemes of the Central Government) Please tick .which ever is applicable and strikeout (.) which ever not applicable Note: "Local Borns" means the descendants of Pre-1942 settlers comprising freedom fighters, convicts, Govt. Servants, Professionals and businessmen who came to these islands and settled here before 1942" 8. Since when the Father, Mother and Husband / Wife is residing in these Islands with documentary evidence, if any. Name Residing Since(Year) Place of Residence ................... 9.Status of Parent(s)/Husband (A) Constitutional Posts: Father Mother Husband (i) Designation (B) Government Service (i) Service (Central/State): (ii) Designation: (iii)Scale of Pay, Including classification, if any (iv)Date of appointment to the post (v) Age at the time of promotion to Class I Post (if applicable) (vi) Gross Annual Income I Enclose Pay Certificate issued by Head of Department/Office II. Employment in International Organisation e.g. UN, UNICEF, WHO: (i) Name of Organisation (ii) Designation (iii) Period of Service ...........................(indicate date from ...... to ...........) (iv) Gross Annual Income .......... Enclose Pay Certificate by Head of Department/Office/ Organisation III. Death/Permanent Incapacitation (Omit if not applicable) (i) Date of death/Permanent incapacitation putting an officer out of service (ii) Details of Permanent Incapacitation (C)Employment in Public-Sector-Undertakings etc (i) Name of Organisation (ii) Designation (iii) Date of appointment to the Post (iv) Gross Annual Income Enclose Pay Certificate by Head of Department/Office/Organisation (D) Armed Forces including Paramilitary Forces (This will not include persons holding civil posts) (i) Designation (ii) Scale of Pay (iii) Gross Annual Income Enclose Pay Certificate by Head of Department/Office (E) Professional class (other than those covered in item Nos. B &C) and those engaged in trade, Business and Industry (i) Occupation/Profession (ii) Gross Annual Income (F) PROPERTY OWNERS I. Agricultural Land Holding: owned by mother, father & minor children (i) Location (ii) Size of holding (iii)Unirrigated area II. Plantation (i)Crops/Fruit (ii)Location (iii)Area of Plantation (iv) Gross income from Agriculture Holding (I) and Plantation (II) Enclose certificate obtained from District Revenue Officer not below the rank of Tehsildar. III. Vacant land and/or building in urban areas or urban agglomeration (i) Location of Property (ii) Details of Property (iii) Use to which it is put (iv) Gross Annual Income - (G) Income/Wealth (i) Annual family income from all sources (excluding salaries & income from agricultural land) Whether Tax Payer (if yes, a copy of (Yes/No) the last three years Return be furnished) (iii) Whether covered in Wealth Tax (Yes/No) Act (if so furnish details) 10. Any other remarks 11. I certify that above said particulars are true to the best of my knowledge and belief and that I do not belong to the Creamy Layer of OBCs and eligible to be considered for posts reserved for OBCs. In the event of any information being found false or incorrect, or ineligibility being detected before or after the selection, I understand that my candidature/appointment is liable to be cancelled and I shall be liable to such further action as may be provided under the law and/or Rules. Yours faithfully, Signature of the candidate Place : Date :
