Annexure B

FORM OF CASTE CERTIFICATE FOR SC/ST

This is to certify that Shri*/ Srimati/ Kumari* ......................................................................... son/daughter* of

………………................................................................ Village/Town
…………….........................................District/Division*............................................................ of
the.....................................................................State/UnionTerritory* belongs to the
……………….................................Caste*/Tribe which is recognised as a Scheduled Caste / Scheduled Tribe under:-
*The Constitution Scheduled Castes Order 1950.
*The Constitution Scheduled Tribes Order 1950.
*The Constitution (Scheduled Castes) (Union Territories) (Part C States) Order 1951;
*The Constitution (Scheduled Tribes) (Union Territories) (Part C States) Order 1951;
[As amended by the Scheduled Castes and Scheduled Tribes Lists (Modification Order 1956, the Bombay Re-organisation Act
1960, the Punjab Re- organisation Act 1966, the State of Himachal Pradesh Act 1970, the North Eastern Areas (Re-
organisation) Act 1971 and the Scheduled Castes and Scheduled Tribes Orders, (Amendment) Act 1976]
*The Constitution (Jammu and Kashmir)* Scheduled Castes Orders, 1956
*The Constitution (Andaman and Nicobar Islands)* Scheduled Tribes Order, 1959 as amended by the Scheduled Castes and
Scheduled *Tribes Orders (Amendment) Act, 1976
*The Constitution (Dadra and Nagar Haveli)* Scheduled Castes Order, 1962.
*The Constitution (Dadra and Nagar Haveli) Scheduled Tribes, Order, 1962
*The Constitution (Pondicherry) Scheduled Castes Orders, 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 & Kashmir) Scheduled Tribes Order, 1989.
*The Constitution (SC) Orders (Amendment) Act, 1990
*The Constitution (ST) Orders (Amendment) Ordinance Act, 1991
*The Constitution (ST) Orders (Amendment) Ordinance Act, 1996
*The Constitution (Scheduled Castes) Orders (Amendment) Act, 2002
*The Constitution (Scheduled Castes) Orders (Second Amendment) Act, 2002.
*The Scheduled Castes and Scheduled Tribes Orders (Amendment) Act, 2002.
2. Applicable in the case of Scheduled Castes/Scheduled Tribes persons who have migrated from one State/Union Territory
Administration.

This certificate is issued on the basis of the Scheduled Castes/ Scheduled Tribes Certificate issued
toShri/Srimati* ..................................................................father/mother*of
Shri/Srimati/Kumari…….…………………………………… of Village/ Town*
…………..............................inDistrict/Division*............................................of the
State/UnionTerritory*…………..………………….who belongs to the ....................................... Caste*/Tribe which is recognised
as a Scheduled Caste/ Scheduled Tribe in the Station/ Union Territory* issued by the..................................................dated
…………………
3. Shri/Srimati/Kumari* ............................................................... and /or* his/her* family ordinarily resides in Village/Town*
................................................ District/ Division*.....................................................of the State/ Union Territory*
of............................................
Place.................................. Signature..................................................................
Date................................... Designation...............................................................
(with seal of Office)
State/ Union Territory................................................
* Please delete the words which are not applicable.
@ Please quote the specific presidential order.
% Delete the Paragraph, which is not applicable
Note: (a) 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 / 1st
Class Stipendiary 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 / her family normally reside(s). 5. Certificates issued by Gazetteed Officers of the
Central or of a State Government Countersigned by the District Magistrate concerned. 6. Administrator/ Secretary to Administrator (Laccadive,
Minicoy and Admindivi Islands).

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 Annexure C

OBC CERTIFICATE FORMAT

FORM OF CERTIFICATE TO BE PRODUCED BY OTHER BACKWARD CLASSES
APPLYING FOR APPOINTMENT TO POST 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 Empowerment’s Resolution No.
……………………………………………………. Dated.................................. *.

Shri/Smt./Kum.* ……................................................................................... and/or his/her family

ordinarily reside(s) in the…....................................................District/Division 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 OM No.
36012/22/93-Estt(SCT), dated 8.9.1993 and modified vide Government of India, Department of
Personnel and Training O.M.No.36033/1/2013-Estt. (Res) dated 27.05.2013 and 13.09.2017**.

Date:
DISTRICT MAGISTRATE /
DY. COMMISSIONER ETC.

(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 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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 Annexure D
DECLARATION

Proforma for declaration to be submitted by Other Backward Class Candidates at the time
of document verification, who had applied for the posts against Employment Notice No.
RRC/WR/03/2024 APPRENTICE OF WESTERN RAILWAY

“I, …………..................................................................................... son/daughter of Shri

................................................................................................. resident of Village/Town/City
............................................................. district ..............................................................State
.......................................... hereby declare that I belong to the .........................................
(indicate your sub caste) community which is recognized as a backward class by the
Government of India for the purpose of reservation in services as per orders contained in
Department of Personnel and Training Office Memorandum No. 36012/22/93-Estt.(SCT)
dated 08.09.1993. It is also declared that I do not belong to persons/sections (Creamy
Layer) mentioned in column 3 of the Schedule to the above referred Office Memorandum
dated 08.03.1993 and its subsequent revision through O.M.No.36033/1/2013-Estt. (Res)
dated 27 05.2013 and 13.09.2017.

Place: Signature of the Candidate

Date: Name of the candidate

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 ANNEXURE – ‘E’
NAME & ADDRESS OF THE INSTITUTE/HOSPITAL
DISABILITY CERTIFICATE

(Paste here recent

passport size
colour photograph
of the Applicants
of size 4 cm x 5 cm

Signature of
Applicants

Certificate No. Date:- __/__/

1. This is to certify that Smt, / Shri / Kum* Son /daughter of Shri______________________

age , Male / Female havingidentification marks as below is suffering from Permanentdisability of
following category.

A. Loco motor or cerebral palsy :

i) BL-Both legs affected but not arms.
j) BA-Both arms affected : a) Impaired reach
b) Weakness of grip
k) OL-one leg affected (right or left): a) Impaired reach
b) Weakness of grip
(c) Ataxic
l) OA-One arm affected (right or left): (a) Impaired reach
(b) Weakness of grip
(c) Ataxic
m) BH-Stiff back and hips (cannot sit or stoop)
n) MW - Muscular weakness and limited physical endurance.
B. Blindness or Low Vision : a) B-Blind
b) PB-Partially Blind
C. Hearing Impairment : a) D-Deaf
b) 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 year months.
3. Percentage of disability in his/her case is Percent.
4. Smt./Shri./Kum* meets the following physical requirement 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 crouching Yes No
(v) B-can perform work by bending Yes No
(vi) S-can perform work 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

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 (x) H-can perform work by hearing / speaking Yes No
(xi) RW-can perform work by reading and writing Yes No

(Signature of Doctor) (Signature of Doctor) (Signature of Doctor)

Name: Name: Name:
Registration No. Registration No. Registration No.
Member, Medical Board Member, Medical Board Member/Chairperson, Medical Board
*Please delete the words which are not applicablePlace:
Date : Counter signature of the Medical
Superintendent/CMO/ Head of Hospital(with seal)
Note:
(i) according to the persons with Disabilities (Equal Opportunities, Protection of Rights and full participation) Rules,
1996 notified on 31.12.1996 by the Central Government in exercise of the powers conferred by sub-Section(1) and(2)
of Section 73 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act.
1995 (1 0f 1996), authorities to give disability Certificate will be a Medical Board duly constituted by the Central or
the State Government. The State Government may constitute a Medical Board consisting of at least three members
out of whom at least one shall be a specialist in the particular field for assessing locomotors/ hearing and speech
disability, mental retardation and leprosy cured asthe case may be.
(ii) The certificate would be valid for a period of 5 years for those whose disability is temporary. For those who
acquired permanent disability, the validity can be shown as permanent.

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 ANNEXURE – ‘F’
Disability Certificate FORM
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)
(See Rule 4)

Recent PP Size
Attested
Photograph
(Showing face
only) of the
person with
disability

Certificate No. ________________________ Date: / /

This is to certify that we have carefully examined Shri /Smt./Kum.______________________________ son / wife /
daughter of Shri Date of Birth (dd/mm/yyyy) Age years, Male/Female Registration No.
_______________ ____ Permanent Resident of House No. _ Ward/Village/Street whose photograph is
affixed above and are satisfied that he/she is a case of _______________________ disability. His/her extent of
percentage physical impairment/disability has been evaluated as per guidelines (to be specified and is shown
against the relevant disability in the table below :-

S.No Disability Affected part Diagnosis Permanent physical

of Body impairment/mental
disability (in %)
1 Locomotor disability @
2 Low vision #
3 Blindness Both Eyes
4 Hearing impairment $
5 Mental retardation X
6 Mental-illness X
(A) In the light of the above, his/her over all permanent physical impairment as per guidelines (to be specified), isas
follows:
In figures: .................................................... percent
In words ......................................................................................................... percent
2. This condition is progressive/non-progressive/likely to improve/not likely to improve.
3. Reassessment of disability is :
I) not necessary, Or
II) is recommended/after ..................... year .......................................... months, and therefore this certificate
shall be valid till ............... (DD/MM/YYYY) @ e.g. Left/Right/both arms/legs # e.g Single eye/both eyes £
e.g. Left/Right/both ears
4. The applicant has submitted the following document as proof of residence:
Nature of Document Date of Issue Details of authority issuing
Certificate

(Authorised Signatory of Notified Countersigned: (Countersignature and seal of the CMO / Medical
Medical Authority) (Name and Superintendent / Head of Government Hospital in case the certificate
Seal) is issued by a medical authority who is not a Government Servant
(With Seal)

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 Annexure G
SCHEDULE-II (See rule 4 of Apprenticeship Rules 1992)
Medical Fitness Certificate for Standard of physical fitness for engagement as Act Apprentice over
Western Railway
Name of the Candidate : …………………………………………………………..

Father’s name : ………………………………………………………….. Paste here recent passport

size photo as uploaded inonline
Category : ………………………………………………………….. application form

Date of Birth / Age : …………………………………………………………..

Trade & Name : ………………………………………………………….. Photo to be attested by medical

officer
Permanent marks of identification 1 ………………………………………………………….

2 ………………………………………………………….

Observations of
Sr. Standard of physical fitness
Medical Officer
No.
1. A candidate should be free evidence of any contagious or infectious disease. He should not
be suffering from any disease which is likely to be aggravated by service or is likely to
render him unfit for service or endanger the health of the public. He should also be free
from evidence of tuberculosis in any form, active or healed.
2. Height, Weight And Chest
Candidates should satisfy the following minimum standards, namely:-
HEIGHT: 137 centimeters; Weight:25.4 Kilogram; Chest expansion should not be less than
3.8 centimeters irrespective of size of chest:

Provide that where a candidate does not satisfy the said minimum standards but is certified
in writing by a Medical Officer not below the rank of an Assistant Surgeon (Gazetted), to be
physically fit for being engaged as an apprentice in a particular trade under the Apprentices
Act,1961, he may be engaged as an apprentice in that trade.
3. EYES
There should be no evidence of any morbid condition of either eye of the lids of either eye
which may be liable to risk of aggravation of recurrence.
Standard of Vision
(A) Visual acuity: *Candidates having vision in one eye shall eligible to undergo
apprenticeship training except in the following seventeen trades, namely :-
(1) Electrician Aircraft (2) Watch and Clock Mechanic
(3) Driver cum Fitter (4) Surveyor
(5) Process Cameraman (6) Sirdar
(7) Rigger(Engg. & Chem. Industry) (8) Shortfirer/Blaster (Mines)
(9) Mate (Mines) (10) Mech. Radio & Radar Aircraft
(11) Ceramic Moduler (12) Ceramic Caster
(13) Ceramic Kiln Operator (14) Ceramic Press Operator
(15) Ceramic Modeller (16) Ceramic Decorator
(17) Optical worker
(b) Colour vision: Not required
4. EARS
Hearing must be good in both ears and there should be no sign of suppurative disease. No
hearing aid shall be permitted.
5. SKIN
There should be no evidence of acute or chronic skin disease or chronic ulceration.
6. SPEECH
Speech should preferably be without impediment.

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S.No. Standard of physical fitness Observations of
Medical Officer
7. ALIMENTARY SYSTEM
1. Candidates should have sufficient number of natural teeth (in healthy state) for
mastication.
2. Spleen should not be palpably enlarged and there should be no evidence of tenderness in
the splenic area.
3. Liver should not be palpable or tender.
4. There should be no oral sepsis.
5. There should be no sugar in the urine.
6. Candidates should not be suffering from haemorrhoids, fissures in and testis anal hernia
or bubonocele or ischio-rectal abscess or hydrocele.
8. CARDIO VASCULAR SYSTEM
1. Blood pressure should not exceed 85 diastolic and 140 systolic. 2. Candidates with low
blood pressure (i.e. systolic below 100) should be rejected. 3. There should be no sign of
any cardiovascular disease.
9. RESPIRATORY SYSTEM
Candidates should be free from all diseases of respiratory system. There should be no
deformity of chest which may cause impediment to breathing.
10. GENITO URINARY SYSTEM
There should be no evidence of genito urinary disease or any abnormality.
11. SKELETAL SYSTEM
1. The function of all limbs should be within normal limits.
2. There should be no evidence of serious deformity of the spinal column or of the
extremities.
12. NERVOUS SYSTEM
There should be no evidence of any disease of nervous system or of any mental disease.
13. GLANDULAR SYSTEM
There should be no evidence of tuberculosis or other disease of the glandular system
including the endocrine glands.
Above medical fitness certificate should be signed by Government authorized Doctor(Gaz), not below the rank
of Assistant Surgeon of Central/State Hospital.

Signature of Medical Officer

Name of Medical Officer

Registration No.

Designation

Name of Central/State Govt. Hospital

Seal of Medical Officer signing the

certificate

27
 Annexure H

Government of

(Name & Address of the authority issuing the certificate)

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY

ECONOMICALLY WEAKER SECTIONS (EWS)

Certificate No. Date:

VALID FOR THE YEAR

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. 8lakh
(Rupees Eight Lakh only) for the financial year . 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;
Ill. 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 municipalities.

2. Shri/Smt./Kumari belongs to the caste which is not

recognized as a Scheduled Caste, Scheduled Tribe and Other Backward Classes (Central List).

Signature with seal of Office

Name_
Designation
Recent Passport size
Attested Photograph of
the Applicant

*Note 1: Income covered all sources i.e. salary, agriculture, business, profession, etc.

**Note 2:The term 'Family" for this purpose include 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.

***Note 3: The property 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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