APPLICATION  FORM  SCHEDULED CASTE  / SCHEDULED TRIBE / BACKWARD  CLASS 
To,
The Mandal Revenue Officer

Sir,

1. Name of the Applicant	: ………………......................................................
(in Block letters & Full)
2. Father's Name	 :  ........................................................................................
3.  Sex			:  .........................................................................................
4. Native place	: ..........................................................................................
(Origin District)
5.  Present Address H.No. : ..................................................................................
6. Caste Claimed 	:  .........................................................................................
7. List of Documents enclosed :............................................................................
    TC from the recognised School or College:
      Caste Certificate earlier if any to the family member
8. Present Age (affidavit duly enclosed) : .............................................................
9. Copy of the Ration Card :.................................................................................
10.Two Gazetted Officers' Certificates	:  ...............................................................
Declaration
I declare that the information furnished by me in the application is true and correct and that if it is found to be untrue and incorrect, I will be liable for prosecution for furnishing false  information under section 199 and 200 of IPC.
Signature of the Applicant
(                                     )
Form FoR Caste Certificate

This is to certify that the claim of Sri / Smt / Kum ................................................
S/o. D/o. w/o ...............village / town H.No. .............................taluk ...................
....................in the dist .................................... of the state..................................... has been  verified  as per the procedure laid down and he / she belongs to the ...……………… SC / ST Backward classes under ......................
The Constitution (Schedule Castes) Order, 1950
The Constitution (Schedule Tribe) order, 1950
G O Ms. No. 1793 Education date 23-9-70 as amended from time to time. (As amended by the Scheduled Castes and Scheduled Tribe Lists (Modification) order 1956 the Sc & ST (amended)
2. Sri/Smt/Kum........................................... and his/her family ordinarily reside in village/ town H.No. .........................of Dist./Divn..........................of the State of ......................................... .
		Signature of the Gazetted Officer
		Date:
		Designation:
		Office Seal:
		NAME:

GOVERNMENT OF ANDHRA PRADESH

Revenue Department			Office of the 
					Mandal Revenue Officer
					........................... Mandal
					Dated:
No.D/                 /2000

Annexure III (B)
FORM OF CASTE CERTIFICATE

This is to certify that the claim of Shri/Smt/Kum...................................................
......................................................S/0 D/o W/o ..................................................
Village/Town H.No........................, .................... Mandal in the ............. District  of the State of Andhra Pradesh has been  verified as per the procedure laid down and he/she belongs to the  ..........................Community/which is recognised as 'BACKWARD CLASS' under Group...................................
Sl.No..........................................

2. Shri/Smt./Kum................................ and his/her family ordinarily resides in village/Town H.No.........., ............District of the State of Andhra Pradesh.
This Certificate is issued for the purpose of  education /job purpose only.
Place: 
Date:				           
MANDAL REVENUE OFFICER
				       ........................................Mandal.