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1 : Applicant Information FORM-16 [rule 14] EDUCATION Application Form No: ED-2020-00078714 Application Form for Verification of Other Backward Class 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 Other Backward Class. Respected Sir / Madam , I, the undersigned JAGTAP VAISHNAVI CHANDRAKANT 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) JAGTAP VAISHNAVI CHANDRAKANT Marital Status : Single Email ID : [email protected] Mobile No. : 9325802591 Aadhaar No.: 744336559580 Date Of Birth: 16/09/2003 Birth Place: AMALNER Category : Other Backward Class Caste : Sutar (174) Applicants Caste Certificate No.: Caste Certificate Issuing Date: Caste Certificate Issuing District: 39591408917 01/08/2019 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 Affidavit Caste Certificate of the Father Bonafide Certificate Caste Validity Certificate in Blood Relative Photo ID of Applicant Purpose Of Scrutiny For Professional Education after Std. X / XII Page 1 Mother Tongue: Marathi Regional Dialect: MARATHI God/Goddess Name: CHIRAIMATA Five different surnames of relatives or person from the same caste of the applicant: JAGTAP DEORE MORE SHARDUL BORSE 2 : APPLICANT ADDRESS Correspondence Address : Permanent Address: PANDIT NAGAR KUSUMBA PANDIT NAGAR KUSUMBA 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) : 2000 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 ADARSH 2012 2013 Other Sutar (174) -- Completed Education PRATAHMIK Backward VIDYAMANDIR Class KUSUMBA DHULE 2 Secondary ADARSH HIGH 2013 2019 Other Sutar (174) -- Completed Education SCHOOL KUSUMBA Backward DHULE Class 3 College ADARSH JUNIOR 2019 2021 Other Sutar (174) -- In Progress Education COLLEGE Backward KUSUMBA DHULE Class Page 2 4 : APPLICANT'S FAMILY DETAILS Full Name of Applicant's Father: CHANDRAKANT PUNA JAGTAP Full Name of the Applicant's Grand Father: PUNA KALU JAGTAP Permanent Address of Father (If Father is not alive, then please mention full address of his last Residence) : PANDIT NAGAR. KUSUMBA 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 PKENDRA SHALA 1985 1988 Other Sutar (174) -- Completed Education KRAMANK 2 DHULE Backward Class Applicant's Father Occupation: Contact Number: Inherited Profession of Family: Business 9325802591 MACHANIC Office/ Business address with contact No: KUSUMBA 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: JAGTAP PUJA LAXMAN 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? : 2013 Caste Validity Certificate No. of relative: 1029875 Date of issue of Caste Validity Certificate: 27/03/2015 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: 04-11-2020 Applicant's Father/Guardian Signature/Left Thumb Impression Page 7.
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