APPLICATION FORM FOR SCHEDULED CASTE/SCHEDULED TRIBE CERTIFICATE 1. Name in full (in capital letters) : 2. Name (in full with alias) : 3. (a) Have you ever changed your name ? : If so, what was your previous name ? : (b) Furnish attested copy of H.S.L.C/School : Certificate. 4. If married woman/widow, state maiden's name : 5. Present address (place) Village. District with : Police Station. 6. Father's name : 7. Mother's name : 8. What was your father's nationality at the time : of your birth ? 9. Your nationality with caste/tribe : 10. Home address : 11. Your religion : 12. Have you ever changed your religion ? : If so, what was your previous religion ? 13. Have you migrated to this State from another State ? : If so, name of the State from where you have migrated. 14. If you migrated from another part of this State, : Furnish the name of the place and District from where You have migrated. 15. (For Scheduled Caste only). If you are adopted : give particulars of caste, religion and address of your parent as well as of the adopted parents. I do hereby by declare that the statement made above are true to the best of my knowledge and belief I have not applied for a certificate before. If the statement is found falsely stated, I shall bound to be dealt with accordingly. Date: Remarks of Gazetted Officer Signature of the Applicant.
