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1 : Applicant Information FORM-16 [rule 14] EDUCATION Application Form No: ED-2021-00181713 Application Form for Verification of Scheduled Caste Converted To Buddhism To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, Hingoli. Dr Babasaheb Ambedkar Social Jucstice Bhavan Office, Hingoli-431701 Subject :- Verification of Scheduled Caste Converted To Buddhism. Respected Sir / Madam , I, the undersigned PANDIT POOJA MUKUND hereby request to verify my Caste Certificate of Scheduled Caste Converted To Buddhism. 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) PANDIT POOJA MUKUND Marital Status : Single Email ID : [email protected] Mobile No. : 7263013663 Aadhaar No.: 561613690791 Date Of Birth: 01/03/2003 Birth Place: Akhada balapur Category : Scheduled Caste Converted To Buddhism Caste : Before Conversion to the Buddhism to the Scheduled Caste Community at SR No (37) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: 2014/Caste/BUD/CR-/3712/010/2014 17/07/2014 Hingoli Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Kalamnuri Name of the Document on which Caste Certificate is Obtained from Competent Authority: Applicant School LC/TC Father School LC/TC Caste Certificate of the Father Ration Card Other Oth.Doc : certificate of police patil, caste certificate of persons in blood realtion Purpose Of Scrutiny To Avail the benefits under Admission in Reserved Category 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: Narwade Wadve Thorat Dhage Muneshwar 2 : APPLICANT ADDRESS Correspondence Address : Permanent Address: B sara orchids , ranubai mala , chakan shewala road Akhada balapur Country : India State : Maharashtra Country : India State : Maharashtra District : Pune Taluka : Khed District : Hingoli Taluka : Kalamnuri Pin code : 410501 Pin code : 431701 Since when applicant is residing at Correspondence address (YYYY) : 2019 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 mother teresa eng 2009 2013 Scheduled Before -- Completed Education school, Akhada Caste Conversion balapur Converted to the To Buddhism Buddhism to the Scheduled Caste Community at SR No (37) 2 Primary ZP high school Ak 2013 2014 Scheduled Before -- Completed Education balapur Caste Conversion Converted to the To Buddhism Buddhism to the Scheduled Caste Community at SR No (37) Page 2 3 Secondary Jawahar navodaya 2014 2021 Scheduled Before -- In Progress Education vidyalaya Caste Conversion ,basmatnagar,hingoli Converted to the To Buddhism Buddhism to the Scheduled Caste Community at SR No (37) Page 3 4 : APPLICANT'S FAMILY DETAILS Full Name of Applicant's Father: Mukund Sambhaji Pandit Full Name of the Applicant's Grand Father: Sambhaji Gendba Pandit Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : navi abadi. shewala road Country : India State : Maharashtra District : Hingoli Taluka : Kalamnuri Pin code : 431701 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 ZP high school 1981 1991 Scheduled Before -- Completed Education ,Akhada balapur, Tq Caste Conversion kalamnuri .dist hingoli Converted to the To Buddhism Buddhism to the Scheduled Caste Community at SR No (37) Applicant's Father Occupation: Contact Number: Inherited Profession of Family: Daily wages 8766559184 FARMING Office/ Business address with contact No: chakan, pune 8766559184 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? : Father When left Native place (YYYY)? 2019 Reason For Leaving : others : daily wages Whether Applicant/ Applicant's family holding house/land at native place? Yes No Name of the relative who is residing at native Place currently: Sambhaji gendba pandit Relation with Applicant: Grandfather Address Of the Relative staying at Native Place: navi abadi,shawala road,tq kalamnuri, dist hingoli Contact No. of Relative: 9923012246 Email Address of Relative : [email protected] 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: PANDIT NITESH GANESH Relation with Applicant: Paternal Cousin Scrutiny Committee: DISTRICT CASTE CERTIFICATE SCRUTINY COMMITTEE, DISTRICT HINGOLI Purpose Of Scrutiny To Avail the benefits under Admission in Reserved Category Page 5 When Verification took place? : 2017 Caste Validity Certificate No. of relative: 1559006 Date of issue of Caste Validity Certificate: 07/09/2017 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: Hingoli Applicant Signature Date: 28-01-2021 Applicant's Father/Guardian Signature/Left Thumb Impression Page 8.
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