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The document is an application form for the issuance of a caste certificate for other backward classes, detailing mandatory fields and service payment charges. It outlines the required documents, personal details of the applicant, and estimated delivery timelines. The form also includes sections for contact and address information, as well as submitter details.

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urbankaranjia
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23 views3 pages

ViewDocument Do

The document is an application form for the issuance of a caste certificate for other backward classes, detailing mandatory fields and service payment charges. It outlines the required documents, personal details of the applicant, and estimated delivery timelines. The form also includes sections for contact and address information, as well as submitter details.

Uploaded by

urbankaranjia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Court Fee Stamp as required APPLICATION FORM FOR ISSUANCE OF

OTHER BACKWORD CLASSES CASTE CERTIFICATE

(Fields marked are mandatory)


Service Payment Details:
1.Service Charges ofthe kiosk Operator= 18.00

2.Printing Charges per unit= 10.00

3.Scanning Charges per unit= 5.00


4.Degs Charges fee per unit 2.00

(The amount may vary based on no of printing and scaning page counts) Debasmita Mohanta
The Acknowledgement of receipt ofApplication/Delivery of Certificate and
Payments received from the citizens shallbe issued free of cost by the CSC operator to the citizens. T
Documents Required Applicant's signatutre
Mandatory Documents
Supporting Documents 1. ROR
2. Self Declaration
3. Land Pass Book
4.Any other document in support/claim
Delivery Time Lines; Estimated Timelines To Process The Application (Expected Date of Delivery):
Fill all the details in the block letters

Personal Details

Applicant Name : Debasmete Mohante


Gender : femate Marital Status *: 12neetd
Date of Birth
9/04/2010 Age* :5
Parents Details
Father Name*
:Surendra naoth Mohanta
Mother Name

Spouse Details
:Phelamani Mohanta
Spouse Name :-

Relation With Applicant


Contact Details

Phone No :9938057997Mobile No :9935057837


Email -

Permanent Address:- Urban Rural


District
Mayur bhanj Sub Division Keorfls
Tahsil :Karanjia RI Circle
Block
: Karansia VillageWard* :-Karadeha
House No/Name Police Station
*Karsanjia
:-

Post Office :-Rasamtala


Pin
: 757037
Submitter Details
Is applicant and submitter are same?* Yes No
Submitter's Name :-

Relation With Applicant -

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