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1 : Applicant Information FORM-16 [rule 14] EDUCATION Application Form No: ED-2021-00209947 Application Form for Verification of Other Backward Class To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, Thane. Kokan Bhavan, 5th Floor, Room No 524, CBD Belapur, Navi Mumbai-400614 Subject :- Verification of Other Backward Class. Respected Sir / Madam , I, the undersigned NANDINI SHANKAR BHOIR hereby request to verify my Caste Certificate of Other Backward Class. 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) NANDINI SHANKAR BHOIR Marital Status : Single Email ID : [email protected] Mobile No. : 9004403555 Aadhaar No.: Nil Date Of Birth: 30/04/2004 Birth Place: MUMBAI Category : Other Backward Class Caste : Kunbi (83) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: SR.NO.2/13 04/02/2013 Thane Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Thane Name of the Document on which Caste Certificate is Obtained from Competent Authority: Father School LC/TC Grand Father School LC/TC Affidavit Ration Card Purpose Of Scrutiny To Avail the benefits under the Government of India Page 1 Mother Tongue: Marathi Regional Dialect: Marathi God/Goddess Name: Khandoba Five different surnames of relatives or person from the same caste of the applicant: GHOLAP ARAJ PAWAR PATIL LATE 2 : APPLICANT ADDRESS Correspondence Address : Permanent Address: AT KHAPARI TAL MURBAD RAIGAD GALLI,ROAD NO 16 AMBIKA NAGAR, WAGALE ESTATE Country : India State : Maharashtra Country : India State : Maharashtra District : Thane Taluka : Murbad District : Thane Taluka : Thane Pin code : 421402 Pin code : 400604 Since when applicant is residing at Correspondence address (YYYY) : 2004 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 R.S.M.V.P.M THANE 2007 2017 Other Kunbi (83) -- Completed Education Backward Class 2 Secondary G V KHADE 2017 2019 Other Kunbi (83) -- Completed Education VIDYALAY AND JR Backward COLLEGE Class 3 College KRUSHI TANTRA 2019 2021 Other Kunbi (83) -- In Progress Education NIKETAN Backward SARALGAON, Class TAL-MURBAD, DIST-THANE Page 2 4 : APPLICANT'S FAMILY DETAILS Full Name of Applicant's Father: SHANKAR SHIVAJI BHOIR Full Name of the Applicant's Grand Father: SHIVAJI TATYA BHOIR Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : RAIGAD GALLI, ROAD NO 16. AMBIKA NAGAR, WAGALE ESTATE Country : India State : Maharashtra District : Thane Taluka : Thane Pin code : 400604 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 SHALA KRA 1980 1987 Other Kunbi (83) -- Completed Education 33,KISAN NAGAR Backward THANE Class 2 Secondary THANE 1987 1992 Other Kunbi (83) -- Completed Education MAHANAGAR Backward PALIKA SHALA 103, Class KISANNAGAR WAGALE ESTATE THANE Applicant's Father Occupation: Contact Number: Inherited Profession of Family: Service 9004403555 FARMING Office/ Business address with contact No: Meyer Organics Pvt. Ltd, THANE Page 3 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: 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: SNEHA SHANKAR BHOIR Relation with Applicant: Sister Scrutiny Committee: DIVISIONAL CASTE CERTIFICATE SCRUTINY COMMITTEE, KOKAN (MUMBAI), DIVISION COMMITTEE NO. 1,(RAIGHAD,THANE) Purpose Of Scrutiny For Professional Education after Std. X / XII Page 4 When Verification took place? : 2017 Caste Validity Certificate No. of relative: 1497866 Date of issue of Caste Validity Certificate: 06/09/2017 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 5 (b-7) If any of the above documents are not available, then attach other relevant documents (mention) Page 6 (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: Thane Applicant Signature Date: 27-02-2021 Applicant's Father/Guardian Signature/Left Thumb Impression Page 7.
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