ANNEXURE - IV

PRESCRIBED CERTIFICATE FORMATS

PRESCRIBED FORMAT OF SCHEDULED CASTES (SC) AND SCHEDULED TRIBES (ST) CERTIFICATE

1. This is to certify that Shri/ Shrimati/ Kumari* ____________________________________________________________ son/daughter'

of __________________________________________ o f V i l l a g e / T o w n * _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ District/Division*
of S ta te /Un ion Territ ory * _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ bel o ngs t o t h e
Scheduled Caste / Scheduled Tribe* under :-
 The Constitution (Scheduled Castes) Order, 1950
* The Constitution (Scheduled Tribes) Order, 1950
 The Constitution (Scheduled Castes) (Union Territories) Order, 1951
 The Constitution (Scheduled Tribes) (Union Territories) Order, 1951
[As amended by the Scheduled Castes and Scheduled Tribes Lists (Modification Order) 1956, the Bombay Reorganisation Act, 1960, the
Punjab Reorganisation Act, 1966, the State of Himachal Pradesh Act, 1970, the North Eastern Areas (Reorganisation) Act, 1971, the
Scheduled Castes and Scheduled Tribes Orders (Amendment) Act, 1976 and the Scheduled Castes and Scheduled Tribes Orders
(Amendment) Act, 2002]
* The Constitution (Jammu and Kashmir) Scheduled Castes Order, 1956;
* The Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959, as amended by the Scheduled Castes and Scheduled
Tribes Order (Amendment) Act, 1976;
* The Constitution (Dadara and Nagar Haveli) Scheduled Castes Order, 1962; * The Constitution (Dadara and Nagar Haveli) Scheduled
Tribes Order, 1962;
* The Constitution (Pondicherry) Scheduled Castes Order, 1964; * The Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967;
* The Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968; * The Constitution (Goa, Daman and Diu) Scheduled Tribes Order,
1968; * The Constitution (Nagaland) Scheduled Tribes Order, 1970;
* The Constitution (Sikkim) Scheduled Castes Order, 1978;
* The Constitution (Sikkim) Scheduled Tribes Order, 1978;
* The Constitution (Jammu and Kashmir) Scheduled Tribes Order, 1989;
* The Constitution (Scheduled Castes) Order (Amendment) Act, 1990;
* The Constitution (Scheduled Tribes) Order (Amendment) Act, 1991;
* The Constitution (Scheduled Tribes) Order (Second Amendment) Act, 1991.

2. # This certificate is issued on the basis of the Scheduled Castes / Scheduled Tribes* Certificate issued to Shri / Shrimati*
____________________ father/mother* of Shri /Shrimati /Kumari* ______________________ of Village/Town*
________________________ in District/Division* _________________________ of the State/Union Territory*
_____________________who belongs to the _______________________ Caste / Tribe* which is recognised as a Scheduled
Caste/Scheduled Tribe* in the State / Union Territory* issued by t he __________________ dat ed______________

3. Shri/ Shrimati/ Kumari * _________________________________ and / or* his / her* family ordinarily reside(s)** in Village/Town*
________________________ of ___________________ District/Division* of the State Union Territory* of _________________________
Place: ________________________________ Signature: _______________
Date: ____________________ Designation: ______________
(With seal of the Office)
State/Union Territory* ___________
* Please delete the word(s) which are not applicable.
# Applicable in the case of SC/ST Persons who have migrated from another State/UT.
IMPORTANT NOTES
The term "ordinarily reside(s)**" used here will have the same meaning as in Section 20 of the Representation of the People
Act, 1950. Officers competent to issue Caste/Tribe certificates:
1. District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner / Additional Deputy Commissioner / Deputy
Collector / Ist Class Stipendiary Magistrate / City Magistrate / Sub-Divisional Magistrate / Taluka Magistrate / Executive
Magistrate / Extra Assistant Commissioner.
2. Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.
3. Revenue Officers not below the rank of Tehsildar.
4. Sub-divisional Officer of the area where the candidate and/ or his family normally reside(s).
5. Administrator / Secretary to Administrator / Development Officer (Lakshadweep Island).
6. Certificate issued by any other authority will be rejected.

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 PRESCRIBED FORMAT OF OBC-NCL CERTIFICATE

This is to certify that Shri / Smt. / Kum* _________________________ Son / Daughter* of Shri / Smt.* _______________________ of
Village/Town* ______________ District/Division* _________________ In the ______________ State belongs to the _________________
community which is recognized as a backward class under:
(i) Resolution No. 12011/68/93-BCC(C) dated 10/09/93 published in the Gazette of India Extraordinary Part I Section I No.
186 dated 13/09/93.
(ii) Resolution No. 12011/9/94-BCC dated 19/10/94 published in the Gazette of India Extraordinary Part l Section I No. 163 dated
20/10/94.
(iii) Resolution No. 12011/7/95-BCC dated 24/05/95 published in the Gazette of India Extraordinary Part I Section I No. 88 dated
25/05/95.
(iv) Resolution No. 12011196/94-BCC dated 9/03/96.
(v) Resolution No. 12011/44/96-BCC dated 6/12/96 published in the Gazette of India Extraordinary Part I Section 1 No. 210 dated
11/12/96.
(vi) Resolution No. 12011/13/97-BCC dated 03/12/97.
(vii) Resolution No. 12011/99/94-BCC dated 11/12/97.
(viii) Resolution No. 12011/68/98-BCC dated 27/10/99.
(ix) Resolution No. 12011/88/98-BCC dated 6/12/99 published in the Gazette of India Extraordinary Part I Section 1 No. 270 dated
06/12/99.
(x) Resolution No. 12011/36/99-BCC dated 04/04/2000 published in the Gazette of India Extraordinary Part I Section I No. 71 dated
04/04/2000.
(xi) Resolution No. 12011/44/99-BCC dated 21/09/2000 published in the Gazette of India Extraordinary Part I Section I No. 210
dated 21/09/2000.
(xii) Resolution No. 12015/9/2000-BCC dated 06/09/2001.
(xiii) Resolution No. 12011/1/2001-BCC dated 19/06/2003.
(xiv) Resolution No. 12011/4/2002-BCC dated 13/01/2004.
(xv) Resolution No. 12011/9/2004-BCC dated 16/01/2006 published in the Gazette of India Extraordinary Part I Section I No. 210
dated 16/01/2006.
(xvi) Resolution No. 12011/14/2004-BCC dated 12/03/2007 published in the Gazette of India Extraordinary Part I Section I No. 67'
dated 12/03/2007.
(xvii) Resolution No. 12015/2/2007-BCC dated 18/08/2010.
(xviii) Resolution No. 12015/13/2010-BCC dated 08/12/2011.
Shri / Smt, / Kum. and / or his family ordinarily reside(s) in the District/Division of State. This is also to certify that he/she does not belong to
the persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the Government of India, Department of Personnel & Training G.M. No.
36012122/93-Estt.(SCT) dated 08/09/93 which is modified vide OM No. 36033/3/2004 Estt.(Res.) dated 09/03/2004, further modified vide OM No.
36033/3/2004-Estt. (Res.) dated 14/10/2008 or the latest notification of the Government of India.
Dated:
District Magistrate I
Deputy Commissioner /Any other
Competent Authority

Seal
* Visit http://www.ncbc.nic.in for latest guidelines and updates on the Central List of State-wise OBCs.
**Please delete the word(s) which are not applicable.
*** As listed in the Annexure (for FORM-OBC-NCL)
**** The authority issuing the certificate needs to mention the details of Resolution of Government of India, in which the caste of the candidate is
mentioned as OBC.
NOTE:
a.The term 'Ordinarily resides' used here will have the same meaning as in Section 20 of the Representation of the People Act, 1950.
b.The authorities competent to issue Caste Certificates are indicated below:
(i) District Magistrate/ Additional Magistrate/ Collector/ Deputy Commissioner/ Additional Deputy Commissioner/ Deputy Collector/ 1st Class Stipendiary
Magistrate/ Sub-Divisional magistrate/ Taluka Magistrate/ Executive Magistrate/ Extra Assistant Commissioner (not below the rank of 1st Class
Stipendiary Magistrate).
(ii) Chief Presidency Magistrate / Additional Chief Presidency Magistrate / Presidency Magistrate.
(iii) Revenue Officer not below the rank of Tehsildar' and
(iv) Sub-Divisional Officer of the area where the candidate and/or his family resides

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 PRESCRIBED FORMAT OF ECONOMICALLY WEAKER SECTIONS CERTIFICATE

Government of ...............................................
(Name & Address of the authority issuing the certificate)

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY

WEAKER SECTIONS

Certificate No. ---------------------- Dated ------------

Valid for the year --------------

1. This is to certify that Shri/Smt./Kumari __________________________ son/daughter/wife of

permanent resident of ______________________________________________________
Village/Street ___________________ Post Office District in the State/Union Territory Pin Code whose
photograph is attested below belongs to Economically Weaker Sections, since the gross annual income*
of his/her "family"* is below Rs. 8 lakh (Rupees Eight Lakh only) for the financial year 2021-2022.
His/her family does not own or possess any of the following assets***:

I. 5 acres of agricultural land and above;

II. Residential flat of 1000 sq. ft. and above;
III. Residential plot of 100 sq. yards and above in notified municipalities;
IV. Residential plot of 200 sq. yards and above in areas other than the notified m unicipalities.

2. Shri/Smt./Kumari ___________________________ belongs to the __________ caste which is

not recognized as a Schedule Caste, Schedule Tribe and Other Backward Classes (Central List).

Signature with seal of Officer _________

Name _____________________________
Designation
Recent Passport size
attested photograph The income and assets of the families as mentioned
of the applicant would be required to be certified by an officer not
below the rank of Tehsildar in the States/UTs.

* Note l: Income covered all sources i.e. salary, agricultural, business, profession, etc.
** Note2: The term "Family" for this purpose includes the person, who seeks benefit of reservation, his/her parents and
siblings below the age of 18 years as also his/her spouse and children below the age of 18 years.
*** Note3: The property(ies) held by a "Family" in different locations or different places/cities have been
clubbed while applying the land or property holding test to determine EWS status.

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 PRESCRIBED FORMAT OF EDUCATIONAL CONCESSION CERTIFICATE (ECC)
(On the proper Letter Head with complete address, telephone number(s) and e-mail ID)
OFFICE OF THE ________________________

This is to certify that Mr. / Miss. _ _ is son / daughter of _______________ _ (No.

_ ) resident of _ .

The above named officer / JCO / OR_ _:

Priority – I
Widows / Wards of Defence personnel killed in action on ______________ during ;
Priority – II
Wards of disabled in action on_ _during _________and boarded
out from service with disability attributable to military service.

Priority – III
Widows / Wards of Defence Personnel who died while in service with death attributable to military service.

Priority – IV
Wards of Defence Personnel disabled in service and boarded out with disability attributable to the military service.

Priority – V
Wards of Serving / Ex-servicemen personnel including personnel of police forces who are in receipt of Gallantry Awards;
i. ParamVir Chakra
ii. Ashok Chakra
iii. MahaVir Chakra
iv. Kirti Chakra
v. Vir Chakra
vi. Shaurya Chakra
vii. President‘s Police Medal for Gallantry/President’s Fire Service Medal for Gallantry
viii. Sena, NauSena, VayuSena Medal
ix. Mention-in-Despatches
x. Police Medal for Gallantry/Gallantry Medal for Fire Services/Fire Service Medal for Gallantry.

Priority – VI
Wards of Ex- Servicemen

Priority – VII
Wives of:
i. Defence Personnel disabled in action and boarded out from service.
ii. Defence Personnel disabled in service and boarded out with disability attributable to military service.
iii. Ex-Servicemen and Serving Personnel who are in receipt of Gallantry Awards.

Priority – VIII
Wards of Serving Personnel
Priority – IX

Wives of Serving Personnel

Mr. / Miss. / Mrs. son / daughter / wife of _______Officer / JCO / OR is eligible for
educational concession for admission in University of Delhi against the Armed Forces Category under Priority No. _.

No.: _Date:

Seal <Rubber Stamp> with Name & Designation

(Signature)

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 PRESCRIBED FORMAT OF PERSONS WITH BENCHMARK DISABILITIES CERTIFICATE

FORM-II
Disability Certificate
(In cases of amputation or complete permanent paralysis of limbs and in cases of blindness)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Recent PP size
attested
photograph
(showing face only) of
the person with
disability

Certificate No. Date:

This is to certify that I have carefully examined Shri/Smt./Kum. _______________________________________

_________________ son/wife/daughter of Shri_________________________________________________ Date of
Birth (DD/MM/YY) _____________________________Age________________________ years, male/female
___________________Registration No. _________________________________ permanent resident of House No.
_________________________ Ward/Village/ Street _____________________________________________
Post Office District State
___________________________________ , whose photograph is affixed above, and am satisfied that:

1. he/she is a case of:

a . l o c o mo to r d i s a b i l i ty
b. blindness
(Please tick as applicable)
2. the diagnosis in his/her case is _____________________________________________
3. He/ She has _____________________ % (in figure) ____________________________________________ per cent
(in words) permanent physical impairment/blindness in relation to his/her ___________________________
(part of body) as per guidelines (to be specified).
4. The applicant has submitted the following document as proof of residence: -

Nature of Document Date of Issue Details of authority issuing certificate

(Signature and Seat of Authorised Signatory of notified Medical Authority)

(Signature/Thumb impression of the person in whose favour the disability certificate is issued.)

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 MEDICAL FITNESS CERTIFICATE FORMAT
For Admission to B.Sc. Physical Education, Health Education & Sports
Department of Physical Education & Sports Sciences
(Faculty of Inter-disciplinary & Applied Sciences) University of Delhi, C/O IGIPESS, B-
Block, Vikaspuri, New Delhi-110018.
Website: www.dudpess.du.ac.in email: dudpess1@gmail.com

1. NAME OF THE COURSE ................................................................

2. NAME: ................................................................................................

3. AGE & GENDER................................................................................................................

4. FATHER’S NAME .............................................................................................................

5. MOTHER’S NAME ............................................................................................................

6. PULSE: ................................................................................................................................

7. B.P.: .....................................................................................................................................

8. WEIGHT: ............................................................................................................................

9. HEIGHT: .............................................................................................................................

10. CHEST CIRCUMFERENCE: NORMAL AND EXPANDED:………………………….

11. CVS: ............................................................................................................................. .......

12. CHEST: ............................................................................................................... ................

13. ABDOMEN: ................................................................................................................ ……

14. EYE: (i) Colour Vision……………………….... (ii) Visual acuity....................................

(a) Without Glasses……………………………… (b) With Glasses…………….………….

15. After careful personal Examination of Mr. / Ms……………………………………………

I hereby certify that he/she is fit to take the Physical Fitness Test for admission to the Program

B.Sc (Physical Education, Health Education, and Sports), University of Delhi.

SIGNATURE OF CANDIDATE (with date)

SIGNATURE OF MEDICAL OFFICER (with

date)
(with stamp, Registration Number, Mobile No.)
(Medical Officer should have a minimum of M.B.B.S. Degree)
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