ANNEXURE–IV: DOMICILE CERTIFICATE PROFORMA

Proforma for Residential/Domicile Certificate

PROFORMA - A-I
Applicable for candidates residing in the State of ________________ continuously at least
for last ten (10) years as on 30.12.2018

To be issued by authorized persons other than Head of the Institution from which the candidate
appeared/is due to appear in '10+2' or equivalent examination.

Domicile Certificate: Type-A-I

Certified that _______________________________________________________________ son / daughter of

____________________________________________is a resident/permanent resident of ____________________
state at Village/House No.____________________________________________

Street_______________________________________________________

Post Office ______________________________ Police Station __________________________________

in the district of ________________________ under Assembly Constituency _______________________ and has been
living in the State of __________________________ continuously / uninterruptedly at least for the last ten (10) years
as on 15-12-2018

Note:

Paste passport size • Photograph is to be attested by the certifying authority.

photograph
ofapplicant in • Candidates must submit the same photograph, as used in the
thisbox Confirmation Page. The same photograph should be used during his/ her
admission through this system.

Signature of Certifying Authority ___________________________________________________________

Designation with Official Seal ______________________________________________________________
Full Name of Certifying Authority ___________________________________________________________
Address ______________________________________________________________________________
Phone No. _______________________________________ Mobile No. ___________________________
ID No. _______________________

Note : The Certifying Authority may please preserve the duplicate copy of the Certificate in his/her Office provided
by the candidate.

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 Proforma for Residential/Domicile Certificate
PROFORMA - A-II
Applicable for candidates residing in the State of ________________ continuously at least for last
ten (10) years as on 30.12.2018
To be issued by the Head of the Institution from which the candidateappeared/is due to appear in
'10+2' or equivalent examination.
Domicile Certificate: Type-A-II

Certified that _______________________________________________________________ son /

daughter of ____________________________________________is a resident/permanent resident of

____________________ state at Village/House

No.____________________________________________

Street_______________________________________________________

Post Office ____________________________ Police Station ______________________________

in the district of ________________________ under Assembly Constituency

_______________________ and has been living in the State of __________________________

continuously / uninterruptedly at least for the las t ten (10 ) years as on 30-12 -2018
Note:

Paste passport size • Photograph is to be attested by the certifying authority.

photograph
ofapplicant in • Candidates must submit the same photograph, as used in the
thisbox Confirmation Page. The same photograph should be used during his/ her
admission through this system.

Signature of Certifying Authority _____________________________________________________

Designation with Official Seal ________________________________________________________

Full Name of Certifying Authority ___________________________________________________

Address _______________________________________________________________________

Phone No. _________________________________ Mobile No. ___________________________

ID No. _______________________
Note : The Certifying Authority may please preserve the duplicate copy of the Certificate in his/her Office provided by
the candidate.

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 Proforma for Residential/Domicile Certificate
PROFORMA - B

Applicable for candidates not residing in the State of _____________ but whose
parent(s) is/are permanent resident(s) of West Bengal having their permanent home
address within the State.

To be issued by authorized persons other than Head of the Institution from which the candidate
appeared/is due to appear in '10+2' or equivalent examination.

Domicile Certificate : Type-B

Certified that _______________________________________________________ Father / Mother of

____________________________________________________(the applicant) is permanent resident

of __________ at Village / House No. _____________________ Street ________________________

________________________ Post Office _____________________Police Station _________________

in the District of ________________________________________________________

under
AssemblyConstituency__________________________________________________________________
______

Note:

Paste passport size Paste passport size  Photograph is to be attested by the certifying authority.

photograph of photograph of  Candidate must submit the same photograph, as used in
applicant in this Father/Mother of the Confirmation Page. The same photograph should be
box applicant used during his/her admission through this system.

Signature of Certifying Authority _____________________________________________________________

Designation with Official Seal _______________________________________________________________

Full Name of Certifying Authority ____________________________________________________________

Address ________________________________________________________________________________

Phone No. __________________________ Mobile No.___________________________________________

ID No. ______________________________

Note : The Certifying Authority may please preserve the duplicate copy of the Certificate in his/her Office provided by
the candidate.

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