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1 : Applicant Information FORM-16 [rule 14] EDUCATION Application Form No: ED-2020-00089225 Application Form for Verification of Nomadic Tribe (C) To, Member Secretary and Research Officer, District Caste Certificate Scrutiny Committee, Dhule. Dr Babasaheb Ambedkar Social Justice Bhavan, Behind Irrigation Building, Near Vidhyavardhini College, Sakri Road, Dhule-424001 Subject :- Verification of Nomadic Tribe (C). Respected Sir / Madam , I, the undersigned DHANGAR SHUBHAM KAILAS hereby request to verify my Caste Certificate of Nomadic Tribe (C). 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) DHANGAR SHUBHAM KAILAS Marital Status : Single Email ID : [email protected] Mobile No. : 9022364956 Aadhaar No.: 591465590745 Date Of Birth: 27/10/2002 Birth Place: DHULE Category : Nomadic Tribe (C) Caste : (29)Dhangar Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: 39591405108 24/07/2019 Dhule Designation of Caste Certificate issuing Authority: Sub Divisional Officer , Dhule Name of the Document on which Caste Certificate is Obtained from Competent Authority: Applicant School LC/TC Father School LC/TC Grand Father School LC/TC Bonafide Certificate Caste Validity Certificate in Blood Relative Purpose Of Scrutiny For Professional Education after Std. X / XII Page 1 Mother Tongue: Marathi Regional Dialect: HINDU God/Goddess Name: PATNA DEVI Five different surnames of relatives or person from the same caste of the applicant: PARDESHI DHANGAR NIKAM GADHARI GUJELA 2 : APPLICANT ADDRESS Correspondence Address : Permanent Address: PLOT NO.29, PANZARA COLONY, NEAR ADARSH PLOT NO.29, PANZARA COLONY, NEAR ADARSH HIGH SHCOOL AT POST KUSUMBA, TAL DIST DHULE HIGH SHCOOL AT POST KUSUMBA, TAL DIST DHULE Country : India State : Maharashtra Country : India State : Maharashtra District : Dhule Taluka : Dhule District : Dhule Taluka : Dhule Pin code : 424302 Pin code : 424302 Since when applicant is residing at Correspondence address (YYYY) : 2002 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 SHEVANTI 2009 2011 Nomadic (29)Dhangar -- In Progress Education PRIMARY SCHOOL, Tribe (C) MORANE PR LALING, TAL DIST DHULE 2 Primary ADARSH PRATHMIK 2011 2013 Nomadic (29)Dhangar -- Completed Education VIDYAMANDIR, Tribe (C) KUSUMBA, TAL DIST DHULE 3 Secondary ADARSH HIGH 2013 2019 Nomadic (29)Dhangar -- Completed Education SCHOOL & JR. Tribe (C) COLLEGE, KUSUMBA, TAL DIST DHULE 4 College ADARSH HIGH 2019 2021 Nomadic (29)Dhangar -- In Progress Education SHCOOL & ADARSH Tribe (C) JUNIOR COLLEGE, KUSUMBA, TAL DIST DHULE Page 2 4 : APPLICANT'S FAMILY DETAILS Full Name of Applicant's Father: KAILAS BHIKA PARDESHI Full Name of the Applicant's Grand Father: BHIKA SUPADU PARDESHI DHANGAR Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : AT POST KUSUMBA. TAL DIST DHULE Country : India State : Maharashtra District : Dhule Taluka : Dhule Pin code : 424302 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 Z. P. KENDRA 1971 1978 Other Pardeshi -- Completed Education SHALA, KUSUMBA, Backward (220) TAL DIST DHULE Class Applicant's Father Occupation: Contact Number: Inherited Profession of Family: FARMER 9172680944 NOT APPLICABLE Office/ Business address with contact No: AT POST KUSUMBA, TAL DIST DHULE 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: DHANGAR DHANSHRI KAILAS Relation with Applicant: Sister Scrutiny Committee: DISTRICT CASTE CERTIFICATE SCRUTINY COMMITTEE, DISTRICT DHULE Purpose Of Scrutiny For Professional Education after Std. X / XII Page 4 When Verification took place? : 2015 Caste Validity Certificate No. of relative: 1041368 Date of issue of Caste Validity Certificate: 24/06/2015 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: Dhule Applicant Signature Date: 13-11-2020 Applicant's Father/Guardian Signature/Left Thumb Impression Page 7.
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