No.____________

This is to certify that Sri/Km/Ms ________________________________________________

son / daughter of Shri _____________________ resident of village _____________________

Post Office _____________________ Tehsil ______________ District _________________

(a) belongs to ______________________________ (mention cast here) which is included in the

SC / ST list as notified by the Govt. of India (delete whichever is not applicable).

(b) Shri ______________________________ is domicile of _____________________ State.

This certificate is being issued after proper verification.

Signature of Candidate