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ie r's D et ai ls (To be
Na m e of th e Certi filled by th e ce rti
fier: fie r O nly)
Designation:

Office Address: At-:::>S: DCL


-r .v u ch non"
Co nt ac t Nu mb
er :

I he re by certify
ab ov e me nt lon e~ de
nd I am a .... (Tick tai& of th e re5lde
ap pro prl a~ bO nt Checklist for CertH
lt be low )
Ga ze tte d Of fic er
01:'fo overwritln1 0 Issue da le ls filled
ler
· Group A 0 Re sid en t's Ph oto is
cross s·1gned an d cro
O Resident's slgnalure
O ~rt lfl er' s details
vil lag e Panchaya ss sta mp ed (pa pe r to
t Head or Mukhiya ph oto or ph oto ~p
ap er)
Gazetted Of fic er
- Group B
M P/ ML A/ ML C/
Mu nd pa l Council
or
~NC
Te hs ild ar
~ iE '-" '-"1.C ~•
He ild of Recogru
zed Educational Ins
titution
._<,:;s•siQPE .RA·no~ stO~~
ooR
su pe rin te nd en t/
W iir de n/ Ma tro n/
pO
fl.PS CL ··. 1\RUC
of Recognized sh Head of Institutio
elt er ho me s/ Orph n
an.iges
EPFO Of fic er s.n atu ,e &
su mp al the Certifier
. for ma t Is appllc.ab
· This le for PO I do cu me nts at Sl.
,., No s. Nos. 17 , 20 , 21 , 22
& , 31 &
4 DOB dOC\Jments 1t .,. , 4 , 5 14 15 of Sc he du le II of the Aa dh aar (En 32 ; POA do cu me nts at SI. Nos. 23 ,
• rolment an d Up da 24 , 37 , 38, 44 & 4S
te) Regulations, 20 ; POR doc;umenu
16 , H am en de d fro 11 Sl NM. 1~
m time 10 llm t

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