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