FORM IA

SEE RULE 7BB[I]

FORM OF ON LINE APPLICATION FOR OTHER BACKWORD CLASS
To
The Sub-Divisional Officer / D.W.O, Kolkata & Ex-Officio Joint Director, B.C.W,
Balurghat(Sadar) , Dakshin Dinajpur.
Sir,
I do hereby apply for OBC Certificate in the following prescribed proforma, for which particulars are
given below. I hereby undertake that the information is correct to the best of my knowledge and belief and
if anything found contrary I would be liable for that.

Yours faithfully,
Date:
(Signature of applicant / gurdian in case of minor)
Application No : OBCWB05012019/2353 ( Block : Balurghat )
1. (a) Applying for : OBC-B (b) Name of caste : Kurmi
2. Full Name of Applicant : BAIDYA NATH MAHATA
3. Father's Name : KIRAN MAHATA 5. Contact No. : 9614524002
4. (a) Date of Birth : 12/09/1997 6. Email Id. : baidyanath9614@gmail.com
(b) Place of Birth : 7. Adhar No. : XXXXXXXX5761
Village / Ward Police Station District State
BAGALIPUR BALURGHAT DAKSHIN DINAJPUR WEST BENGAL

8. Address since birth (a) Present address:

Para / House No. / Ward No. / G.P. Post Office Police Station District State PIN
Road / Village
BANGALIPUR 11 CHINGISHPUR GP AMRAIL BALURGHAT DAKSHIN WEST 733103
DINAJPUR BENGAL
(b) Other address(s) :
Para / House No. / Road / Village Ward No. / G.P. Post Office District State PIN
BANGALIPUR 11 CHINGISHPUR GP AMRAIL DAKSHIN WEST 733103
DINAJPUR BENGAL

9. Nationality : INDIAN 10. Religion : Hinduism 11. Sex : Male

12. Whether any of the blood relations of the applicant posseses Caste Certificate? Yes
If answer to point no. 12 is 'Yes':
Name of cert. holder Relation with applicant Certificate No. Date of Issue Issuing authority
KIRAN MAHATA FATHER 2660 14/02/1997 BALURGHAT(SADAR)

13. Details of two(2) referees:

Name of 1st referee Address of 1st referee Name of 2nd referee Address of 2nd referee
SWAPAN MAHATA BANGALIPUR TAMIL MAHATA BANGALIPUR

14. Whether the applicant or his family migrated from other State / Country? No
If point no. 14 is 'Yes': Migration Certificate No. : Date of Issue :
Address of the applicant in his/her state of origin.
Village / Ward Police Station District State Country Year

Date: ( Signarure of applicant / gurdian in case of minor )