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Annexure

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES

APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA

This

is

to

certify

that

Shri/Smt./Kumari

____________son/daughter

of

_________________________ of village/town _____________________________________

in

District/Division

_________________________

in

the

State/Union

Territory

____________________ belongs to the ______________________________ community

which is recognised as a backward class under the Government of India, Ministry of Social
Justice

and

Empowerments

Resolution

No.

______________________

________________*. Shri/Smt./Kumari ______________________ and /or his/her

ordinarily

reside(s)

in

the

________________________

District/Division

dated
family
of

the

_________________________ State/Union Territory. 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 O.M. No. 36012/22/93-Estt. (SCT)
dated 8.9.1993**.

District Magistrate
Deputy Commissioner etc.
Dated:

Seal
___________________________________________________________________________
*- The authority issuing the certificate may have to mention the details of Resolution of
Government of India, in which the caste of the candidate is mentioned as OBC.
**- As amended from time to time.
Note:- The term Ordinarily used here will have the same meaning as in Section 20 of the
Representation of the People Act, 1950.

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APPENDIX III
NAME & ADDRESS OF THE INSTITUTE/HOSPITAL
Certificate No. __________________________

Date __________________
DISABILITY CERTIFICATE

This is to certify that Shri / Smt / Kum __________________________________________________

son/wife/daughter of Shri __________________________________________age ________________
sex ___________identification mark (s) _____________________________ is suffering from permanent
disability of following category :

A.

B.

C.

Locomotor or cerebral palay:

(i)
BL-Both legs affected but not arms.
(ii)
BA-Both arms affected
(iii)
(iv)

BLA-Both legs and both arms affected

OL-One leg affected (right or left)

(v)

OA-One arm affected

(a)
(b)

Recent Photograph of
the candidate
showing the disability
duly attested by the
Chairperson of the
Medical Board.

Impaired reach
Weakness of grip

(a)
Impaired reach
(b)
Weakness of grip
(c)
Ataxic
(a) Impaired reach
(b)
Weakness of grip
(c)
Ataxic

(vi)
BH-Stiff back and hips (Cannot sit or stoop)
(vii)
MW-Muscular weakness and limited physical endurance.
Blindness or Low Vision:
(i)
B-Blind
(ii)
PB-Partially Blind
Hearing Impairment:
(i)
D-Deaf
(ii)
PD-Partially Deaf
(Delete the category whichever is not applicable)

2.
This condition is progressive / non-progressive /likely to improve / not likely to improve. Re-assessment of this case
is not recommended / is recommended after a period of ______________years _____________ months.
3.
Percentage of disability in his/her case is _____________percent.
4.
Sh./Smt./Kum __________________________meets the following physical requirements for discharge of his/her
duties.
(i)
F-can perform work by manipulating with fingers.
Yes/No
(ii)
PP-can perform work by pulling and pushing.
Yes/No
(iii)
L-can perform work by lifting.
Yes/No
(iv)
KC-can perform work by Kneeling and crunching.
Yes/No
(v)
B-can perform work by bending.
Yes/No
(vi)
B-can perform by sitting.
Yes/No
(vii)
ST-can perform work by standing.
Yes/No
(viii)
W-can perform work by walking.
Yes/No
(ix)
SE-can perform work by seeing.
Yes/No
(x)
H-can perform work by hearing/speaking.
Yes/No
(xi)
RW-can perform work by reading and writing.
Yes/No
(Dr______________________) (Dr.____________________)
Member
Member
Medical Board
Medical Board

(Dr.______________________)
Chairperson
Medical Board

Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)

Strike out which is not applicable.