FORM-16 [rule 14]

EDUCATION Application Form No: ED-2021-00217589

Application Form for Verification of Scheduled Caste To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, . Residential School, Jail Road, Between Yerwada Jail & Yerwada Mental Hospital, Southern Side Of Commerzone, Yerwada, Pune- 411006

Subject :- Verification of Scheduled Caste.

Respected Sir / Madam , I, the undersigned Panchmukhe Piyush Anil hereby request to verify my Caste Certificate of Scheduled Caste. Following Information and documents are submitted here with in support of my caste claim.

1 : APPLICANT INFORMATION

Full Name of the Applicant: (As Mentioned in Caste Certificate)

Panchmukhe Piyush Anil

Marital Status : Single

Email ID : [email protected] Mobile No. : 9766098224

Aadhaar No.: 883954936366 Date Of Birth: 24/01/2004 Birth Place: Khadki

Category : Scheduled Caste Caste : Mahar (37) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: 100403548 05/06/2010 Pune Designation of Caste Certificate issuing Authority: Deputy Collector Name of the Document on which Caste Certificate is Obtained from Competent Authority: Self Declaration Affidavit Caste Certificate of the Father Bonafide Certificate Ration Card

Purpose Of Scrutiny For Professional Education after Std. X / XII

Page 1 Mother Tongue: Marathi Regional Dialect: Marathi God/Goddess Name: Gautam Buddha

Five different surnames of relatives or person from the same caste of the applicant:

Bhosale Ahiwale Waghchoure Kamble Gaikwad

2 : APPLICANT ADDRESS

Correspondence Address : Permanent Address: A-13, Mithila Nagari Co-op Housing Society ltd 15, Aundh A-13, Mithila Nagari Co-op Housing Society ltd 15, Aundh Road Road

Country : State : Country : India State : Maharashtra

District : Pune Taluka : Haveli District : Pune Taluka : Haveli

Pin code : 411020 Pin code : 411020

Since when applicant is residing at Correspondence address (YYYY) : 2016

3 : APPLICANT EDUCATION DETAILS

S Education Name of Duration of Duration of Applicant Caste (As Other Caste Status r. Educational Education Education Category Mentioned (As (Completed/ N Institute/ School From To In Mentioned In Progress) o /College Address Educational In with Telephone No. Certificate) Educational Certificate) 1 Primary Bhartiya Vidya 2010 2017 Scheduled Mahar (37) -- Completed Education Bhavan Sulochana Caste Natu Vidya Mandir ,Pune 2 Secondary Bharatiya Vidya 2017 2020 Scheduled Mahar (37) -- Completed Education Bhavan's Soluchana Caste Natu Vidya Mandir, Pune

Page 2 4 : APPLICANT'S FAMILY DETAILS

Full Name of Applicant's Father: Anil Vishnu Panchmukhe

Full Name of the Applicant's Grand Father: Vishnu Tukaram Panchmukhe

Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : A-13, Mithila Nagari Co-op Housing Society. 15 Aundh Road Pune

Country : India State : Maharashtra

District : Pune Taluka : Haveli

Pin code : 411020

Is Applicant's Father Literate?: Yes No

S Education Name of Duration of Duration of Applicant Caste Other Caste Status r. Educational Education Education Category (Completed/ N Institute/ School From To In Progress) o /College Address with Telephone No. 1 Primary Mata Ramabai 1970 1974 Scheduled Mahar (37) -- Completed Education Ambedkar Prathmik Caste Vidyala PMC School No-60,Chikhalwadi 2 Secondary Rangehills Secondary 1974 1980 Scheduled Mahar (37) -- Completed Education School, Rangehills, Caste Pune 3 College Alegaonkar Junior 1980 1982 Scheduled Mahar (37) -- Completed Education College, Khadki, Caste Pune 4 College Sanghvi Keshri 1982 1985 Scheduled Mahar (37) -- Completed Education Mahavidyalaya Caste Chinchwad Pune 5 Other Ranade Institute, 1985 1986 Scheduled Mahar (37) -- Completed Pune Caste 6 Other Pune University 1986 1988 Scheduled Mahar (37) -- Completed Caste 7 Other Symbiosis Law 1988 1990 Scheduled Mahar (37) -- Completed College Pune Caste 8 Other Symbiosis Law 1990 1993 Scheduled Mahar (37) -- Completed College Pune Caste

Applicant's Father Occupation: Contact Number: Inherited Profession of Family:

Service 0222308420 --

Page 3 Office/ Business address with contact No: MSRTC Central Office, Maharashtra Vahatuk Bhavan, -400008

Page 4 5 : FAMILY MIGRATION DETAILS

State Migration

Is Applicant/Applicant's Family migrated to Maharashtra State? Yes No

From Which State? : Migration Year? :

Reason For Migration? :

Native Place Migration

Is Applicant/ Applicant's Family left the native place? Yes No

Who Left the place? : When left Native place (YYYY)?

Reason For Leaving : :

Whether Applicant/ Applicant's family holding house/land at native place? Yes No

Name of the relative who is residing at native Place currently: None

Relation with Applicant:

Address Of the Relative staying at Native Place:

Contact No. of Relative: Email Address of Relative :

6 : FAMILY CASTE VALIDITY CERTIFICATE DETAILS

Whether the Caste Validity Certificate Scrutiny of any member of the family has done earlier?: Yes No

Name of Relative: Anil Vishnu Panchmukhe

Relation with Applicant: Father

Scrutiny Committee: DISTRICT CASTE CERTIFICATE SCRUTINY COMMITTEE, DISTRICT PUNE

Purpose Of Scrutiny For Promotion in Reserve Category

Page 5 When Verification took place? : 2010 Caste Validity Certificate No. of relative: 28012

Date of issue of Caste Validity Certificate: 04/02/2010

If Rejected give it's details: No

If applicant has applied for caste validity certificate before any committee in state of Maharashtra: Yes No

Name of Committee:

Category: Caste: Date of Application: Committee Decision: Valid Invalid Pending 7 : UPLOAD DOCUMENTS

WOULD YOU LIKE TO TAKE BENEFIT UNDER BLOOD RELATION FROM PATERNAL SIDE, IF ANY? Yes No

(A) Important Primary Document (Mandatory)-Upload Scan copy of Original Certificate/ Document or upload Self Attested copy in case of Xerox.

(a-1) Caste Certificate of Applicant

(a-2) FORM-17 - Affidavit to be produced alongwith Caste Scrutiny application Form

(a-3) Original Affidavit (In Specimen Form-3, [Rule - 4(1)] Affidavit of Claimant / Parent(s))

(a-4) Form-15A - Certificate to be given by Principal of the School/College

(a-5) Applicant Photo

(a-6) Applicant Signature

(a-7) Applicant's Parent Signature

(B) Important Secondary Documentary Evidence Proof Prior to deem Date only to Prove Caste Claim (Any one of the document can be upload)-Upload Scan copy of Original Certificate/ Document or upload Self Attested copy in case of Xerox.

(b-1) Certified Copy of Birth Certificate of Applicant's or Applicant's Father/Real Elder Uncle/Real Aunt/Grand Father (From Paternal side) issued by Competent Authority Prior to deem Date

(b-2) Certified Copy of Applicant's Primary School Leaving Certificate/School Register's Extract

(b-3) Certified Copy of Applicant's Father Primary School Leaving Certificate/School Register's Extract

(b-4) Certified Copy of School Leaving Certificate/School Register's Extract of Grand Father/Real Elder Uncle'/ Real Aunt (From Paternal Side)

(b-5) If relatives from Paternal side are illiterate, then Birth/Death Extracts of Father/Real Elder Uncle'/ Real Aunt/Grand Father (From Paternal Side) issued by Competent Authority (Village Extract No.14/Kotwar Book/Nationality Register)

(b-5) Any Other documents supporting Caste claim (Applicant can upload multiple VC under Blood Relation type.)

(b-6) Attested Xerox copy of identity card issued by the college

Page 6 (b-7) If any of the above documents are not available, then attach other relevant documents (mention)

Page 7 (b-8) Entry of caste mentioned in the documents of blood relatives from paternal side, registered before deemed date of respective caste category, e.g. sale or purchase deed of land, house or other immovable property, mortgage deed, agreement, inam sanad through which rights have been transferred

(b-9) Entry of caste of blood relatives from paternal side in National Registration Book mainly from Aurangabad Revenue Division.

(b-10) Documents related to Inam land available in the records of Directorate of Archives revealing the evidence of caste

(b-11) Entry of caste in the extract of Village Mutation Register, documents in the Format of `Ka`, `da`, `ee`, patra, entries of caste of blood relatives from paternal side mentioned in the documents of old Court proceedings

(b-12) Government and semi-Government certificates containing traditional Occupation of caste in the old Caste System in respect of ancestors in blood relations from paternal side, entered before deemed date.

(b-13) Old record wherein name of traditional occupation is mentioned as caste In lieu of surname.

(b-14) Sanad or Proceedings before deemed date, in which the tenant has been declared as the landlord, as per the provisions of the Maharashtra Tenancy and Agricultural Lands Act (LXVII of 1948) or any other law, revealing the entry of caste.

(b-15) Entries of caste in Census record entered before deemed date.

I am producing certified copy of above documents with my application. I declare on oath that the information furnished by me in this application is true and correct. I am aware that incomplete application will be rejected and responsibility of making fresh application will be of mine.

Place: Pune Applicant Signature

Date: 24-03-2021

Applicant's Father/Guardian Signature/Left Thumb Impression

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