Government of West Bengal
Backward Classes Welfare Department
Application form for SC/ST/OBC Certificate
1. Application to: State*
District*
Sub-division *
Municipality
Block
*
2. Applying for:  SC   ST  OBC  Caste/Tribe/Community:     *
3. Name:      * 4. Father's name: *
5. Phone No.: 6. Email ID:     
7.(a) Date of Birth: *
       Calendar
(b) Place of Birth: *
    



     
8. Address:
a) Present Address for last 6 months:
    C/O (Name): 
    State: *
    District:
    Police Station: *
    Ward/GP:
    Vill/Para/House No./Road: *
    Post Office: *
    Pin Code :
b) Permanent Address:    Same as present?  Yes    No
    C/O (Name): 
    State: *
    District: *
    Police Station: *
    Ward/GP:
    Vill/Para/House No./Road: *
    Post Office: *
    Pin Code :
Any more?    YES     NO
9. Nationality: 10. Religion: * 11. Gender: *
12. Blood relation (paternal side) details:  
 a) Certificate holder's name: *
 b) Relation with applicant: *
 
 c) Certificate No:
    
 d) Date of issue:
     Calendar
 e) Issuing authority: *
 
 13. Details of two(2) local referees:
 a) Name of Referee-I: *
 b) Address of Referee-I: *
 c) Name of Referee-II: *
 d) Address of Referee-II: *
14. Whether the applicant or his family migrated from other State/Country?     Yes    No
Migration Certificate No:      Date of issue:     
Country
State
District
Police Station
Village/Ward
Year of migration