MET-2011/PAM-CAT-2011

ANNEXURE-4

SPECIMEN OF CERTIFICATES

For the purpose of uniformity for issuing the certificates of residence in the case of various
categories to be issued by the Competent Authorities, the Performas have been prescribed which
are enclosed herewith. After careful consideration, it has also been decided to delete the D.T.O.
included among the certifying authorities against category (iv) and (v) of the policy instructions
dated 29.01.1996.

Affidavit of the Parents/Guardian

(Compulsory for All Candidates)
Affidavit to be attested by an Executive Magistrate/Oath Commissioner/Notary
Public in Case of Category- a and b (Annexure-3)

I father/mother/guardian of
Miss/Mr _______________resident of ___________________
(full address to be given) do hereby solemnly state and affirm as under:

That I am a citizen of India

Neither I, nor my children/ward/dependent have obtained the benefit of residence in any
other State (or any other standard language approved by the Punjab Govt.)

Dated: Deponent

Verification
Verified that the contents of my above affidavit are true and correct to the best of my knowledge
and belief and nothing has been concealed thereof.

Dated: Deponent

RESIDENCE CERTIFICATE
To be issued by the Principal/Headmaster of the Government/Recognized School/College concerned in
case of Category- (i)

It is certified that Miss/Mr. D/o, S/o Sh. has been a student of

this School/College for a period of year, from to
. He/she left the School/College on .

Dated: Signature of Principal/Headmaster of the

School/College (with seal)
 RESIDENCE CERTIFICATE
To be issued by the Head of the Department in case of Category-ii (a)

a) Certified that Shri S/o Shri father of

Miss/Mr. (Name of the Child/Ward) is an employee of (Name of the
office) of Punjab Government. He/She has more than three years service at his/her credit.

OR

b) Certified that Shri S/o Shri father of

Miss/Mr. is an employee of Punjab Government. He/She is working on deputation
with the and is posted at He/She has more than three
years service at his/her credit.

Place: Head of Department

Dated: (with seal)

RESIDENCE CERTIFICATE
To be issued by the Respective Head of the Department in case of Category-ii (b)

Certified that Shri S/o Shri father of Miss/Mr.

is an employee of Govt. of India and is working as . He has been posted at
Chandigarh/Punjab in connection with the affairs of Punjab Government for the past three years.

Dated: Head of Department

(with seal)

RESIDENCE CERTIFICATE
To be issued by the Respective Head of the Department in case of Category-ii (c)

Certified that Shri S/o Shri father of Miss/Mr.

is an employee of Govt. of Punjab (State Government/Institution/ Undertaking and is working
as . He is posted at Chandigarh/Punjab in connection with the affairs of Punjab
Government for the past three years.

Dated: Head of Department

(with seal)
 39

RESIDENCE CERIFICTATE
To be issued by Respective the Head of the Department in case of Category-ii (d)

Certified that Shri S/o Shri father of Miss/Mr.

is an employee of in which the punjab Government has (name of
autonomous body/company) 20% or more share. He/She is working as
and is posted at It is also certified that he/she has
three years service in the above autonomous body/company.

Dated: Head of Department

(with seal)

RESIDENCE CERIFICTATE
To be issued by the DC, ADC(R), ADC(D), SDO(C), GA TO DC, DORG, DRO, DM, Tehsildar,
Commissioners of Municipal Corporation of Amritsar, Jalandhar and Ludhiana in
Case of Category- (iv)

Certified that Shri S/o Shri father/guardian of Miss/Mr.

(name of the child/ward with full address) has settled* in Punjab or has resided* in
Punjab for a period of 5 years from to . He is working
as

* Strike whichever is not applicable.

Dated: Signature(with seal)

RESIDENCE CERIFICTATE
To be issued by the DC, ADC(R), ADC(D), SDO(C), GA TO DC, DORG, DRO, DM, Tehsildar,
Commissioners of Municipal Corporation of Amritsar, Jalandhar and Ludhiana in
Case of Category - (v)

Certified that Shri S/o Shri (Name of persons) father/guardian of

Miss/Mr. (Name of the child/Ward with full address) hold an immovable property at
in the State of Punjab for the past years.

Dated: Signature(with seal)

 40

RESIDENCE CERIFICTATE
To be issued by the DC, ADC(R), ADC(D), SDO(C), GA TO DC, DORG, DRO, DM, Tehsildar,
Commissioners of Municipal Corporation of Amritsar, Jalandhar and Ludhiana in
Case of Category-(vi)

Certified that Miss/Mr. D/o, S/o. Shri resident of was

born in Punjab as per Birth Certificate.

Dated: Signature(with seal)

SCHEDULED CASTE/TRIBE CERTIFICATE

To be issued by the District Magistrate/Additional District Magistrate/Collector/Deputy

Commissioner/ Additional Deputy Commissioner/Deputy Collector/First Class Stipendary
Magistrate/City Magistrate/Sub Divisional Magistrate/Taluka Magistrate/Executive
Magistrate/Extra Assistant Commissioner (not below the rank of Ist class Stipendary Magistrate),
Revenue Officer not below the rank of Tehsildar.

1. It is certified that Shri/Smt./Kumari Son/daughter of

Shri. of village/town District/ Division State of
Punjab belongs to caste which has been recognized as Scheduled Caste as per “
The Constitution Scheduled Castes Order 1955”.
2. Shri/ Smt./Kumari and his/her family lives in village/town
District/Division of Punjab State.

Dated: Signature(with seal)

Place:

BACKWARD CLASS CERTIFICATE

To be issued the Sub Divisional Officer(C)/Executive Magistrate/Tehsildar/Naib Tehsildar/ Block

Development Officer/District Revenue Officer/M.L.A. of the concerned constituency.
1. This is to certify that Shri/Smt./Kumari Son/daughter of
Shri of village/town_ in District/Division of
State of Punjab belongs to the caste which is recognized a
Backward Class in terms of Punjab Government Letter
No. Dated _________________________________.

2. This is also certified that he/she does not belong to any category of persons/sections
mentioned in column 3 of the Schedule of Punjab Government, Department of Welfare
Letter No. 1/4/93-RCI/459, dated 17-1-1994 and No8/144/93-BS2/7017, dated 27-9-95.

3. Shri/Smt./Kumari and/or/his/her family ordinarily reside(s) in

village/town of District/Division of the State of
Punjab.

Dated: Signature(with seal)

Place:
 CERTIFICATE FOR FREEDOM FIGHTER
Certificate for being Children/Grand Children of Freedom Fighter
(Grand Children would mean Son’s Son/Daughter or Daughter’s Son/Daughter)

Dispatch No. Date:

Certified that son/daughter of Shri of

village P.O. Tehsil District has been granted
freedom fighter’s pension by the Punjab Government or has been awarded Tamra Patra for his/her
political sufferings.

*Deputy Commissioner
(with Seal of the Court)
*Certificate from no other authority will be accepted

BACKWARD AREA CERTIFICATE

Dispatch No. Date:

Certified that son/daughter of Shri is a bonafide resident of

which has been declared as backward area by
the Punjab Government. His/Her claim falls under Category* indicated below:

*a) a person who with the family members has been residing in particular village or
town/included in the list of areas which are declared backward constantly for a period of
ten years or more and is likely to continue to reside there.
b) a person who has been residing in a village/town for a period of less than ten year but not
less that five years who is likely to reside there on account of the fact that he has obtained
employment and will settle there after retirement.
In case of a person who has been residing in a village or town included in the list of areas
which are declared backward and has migrated to another village or town in the said area,
the total of his stay at both places will be counted.

Dated: **District Magistrate/G.A. to D.C.

Sub-Divisional Officer (Civil)
(With seal of the court)
*Please mention here category (a) or (b) as the case may be
**Certificate from authority other than D.M./G.A. to D.C. or S.D.O.(Civil) is not valid.
 DEFENCE/PARA-MILITARY/PUNJAB POLICE/PAP/PUNJAB HOME GUARDS
PERSONNEL CERTIFICATE

To be obtained from the appropriate authority with dispatch number and date of issue
along with seal of the officer issuing the certificate mentioned in the Prospectus for the
category.

Certificate must indicate the name of the candidate

CERTIFICATE OF DEATH/INCAPACITATION OF MILITARY/PARA-MILITARY

PERSONNEL

Dispatch No. Date:

Certified that Mr./Ms. an applicant for admission to MBA/MCA course, is the

son/daughter/spouse of Mr./Ms. who was killed/incapacitated to
the extent of 50% or more in action or died otherwise in service or incapacitated to the extent of
50% or more while in service during peace time.

Dated: Signature Authorized Officer Headquarter

Official Seal
CERTIFICATE TO BE FURNISHED BY WARDS OF MILITARY/PARA-MILITARY
(EX-SERVICEMEN)

Dispatch No. Date:

This is certified No. Rank

Name is a resident of village/town
and has served in the Indian Armed Forces from to

and has been released/retired vide order No. dated or

discharge certificate issued by is an ex-serviceman.

Mr./Miss/Smt. wife/son/daughter of is
residing with him and is wholly dependent upon him. This certificate has been issued for
admission purpose only to Mr./Miss/Smt to apply for (name of the class
course) in (name of the educational institution)
.

(Strike out which is not applicable)

Deputy Director Sainik Welfare

Place:
 CERTIFICATE TO BE FURNISHED BY WARDS OF MILITARY/PARA-MILITARY
PERSONNEL (IN-SERVICE)

Certified that Mr./Mrs. an applicant to MBA/MCA course is a son/daughter or

Son’s/daughter’s son/daughter/spouse of Mr. Rank
employed in Unit .

Dated: Signature of Commanding Officer of the Unit

Official Seal

CERTIFICATE OF ARMY DESERTERS AFTERMATH OPERATION BLUE STAR

Dispatch No. Date:

Certified that Mr./Ms. an applicant for admission to

MBA/MCA course, is the son/daughter/spouse of Mr./Ms. Rank who
deserted the Army Aftermath of Operation Blue Star.

Place: Deputy Director Sainik Welfare

Dated:

CERTIFICATE OF GALLANTRY AWARD TO POLICE PERSONNEL

Dispatch No. Date:

Certified that Mr./Ms. applicant for admission to

MBA/MCA course is the son/daughter/spouse of Sh. who was awarded
Presidents’s Police Medal for gallantry.

Dated: Signature of Inspector General of Police

Official Seal
FORMAT OF DEATH CERTIFICATE TO BE ISSUED BY THE CONCERNED SUB
DIVISIONAL OFFICER(CIVIL) IN RESPECT OF INNOCENT CIVILIANS
KILLED/100% PHYSICALLY INJURED BY TERRORITS/SECURITY FORCES
ACTING IN AID OF CIVIL AUTHORITIES

Dispatch No. ___________________

It is certified that Mr./Ms son/daughter /wife of

Shri/Smt. resident of
(Name of village, Tehsil in case the deceased belongs to Rural Area and House number,
name of Mohalla and area of town in which he/she belongs) was killed or became 100% physically
disabled by the terrorists/security forces acting in aid of civil authorities on _________ in
Village/Mohalla/Tehsil Town District. He was
neither terrorist nor have any links with such elements.

APPLICABLE TO GOVT. EMPLOYEES ONLY

1. He/She was working as ……………………….. in the Department of

………………………….. at ………………………………………..
2. This certificate is issued on the basis of the report of ………………………..
(Name of Police Authority)
3. The Certificate is issued on the request of Sh. ……………………………….
(Name and relationship of applicant with deceased).

Signature of the SDO (C) concerned with Seal

CERTIFICATE OF DEATH/INCAPACITATION OF
MILITARY/PARA/MILITARY PERSONNEL

Certified that Mr./Miss/Mrs. an applicant for admission to MBA/MCA course,

is the son/daughter/spouse of Mr. who was killed or became hundered
percent incapacitated in terrorist action on
Dated Signature of Authorized Office
Official Seal

CERTIFICATE FOR THE HANDICAPPED CANDIDATES

Dispatch No. Date:

Certified that son/daughter of Shri suffers
from a loss of earning capacity of

a) 50% or more
b) 40% or more but less than 50% as per the criteria laid down by the Punjab Government.

Dated:_____________ Chief Medical Officer