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APPENDIX -1

PROFORMA a1
Residential/Domicile Certificate for candidates residing in the State of West Bengal
continuously for at least last ten (10) years as on 31.12.2021.
Certified that _____________________________________________

Son / daughter of ________________________________is a resident/permanent

resident of West Bengal at Village/House No. ______________________________

Street _____________________________________________________________

Post Office _______________________Police Station _______________________

In the District of _______________________ under ____________________________

Assembly Constituency and has been living in the State of West Bengal continuously /
uninterruptedly at least for the last ten (10) years as on 31-12-2021.

Paste 4 cmx3 cm Candidate’s signature

size recent colour
photograph in this
box
Candidate must sign here in front of the certifying
authority

(Candidate’s photograph)

Signature of Certifying Authority _____________________________________________

Designation with Official Seal ________________________________________________

Full Name of Certifying Authority _____________________________________________

Office Address ____________________________________________________________

Office Phone No. _________________ Mobile No:_________________(optional)

ID No: ______________________________(optional)

Note: Photograph is to be attested by the certifying authority.

The Certifying Authority should preserve a duplicate copy of this Certificate.
 APPENDIX -2

PROFORMA a2
Residential/Domicile Certificate for candidates residing in the State of West Bengal
continuously for at least last ten (10) years as on 31.12.2021.

Certified that ____________________________________________son / daughter of

____________________________________has passed the ‘10+2’ Examination in the
year______ / will appear in the Final ‘10+2’ Examination in 2022 from this Institution.
It is also certified that the student is a resident/permanent resident of West Bengal at
Village/House No. __________________________________________________
Street_____________________________ Post Office ______________________

Police Station ____________________in the district of ____________________

under _____________________ Assembly Constituency and has been living and

studying in the State of West Bengal continuously / uninterruptedly at least for the last
ten (10) years as on 31-12-2021.

Candidate’s signature

Paste 4 cmx3 cm Candidate must sign here in front of the certifying

size recent colour authority
photograph in this
box

(Candidate’s photograph)

Signature of Certifying Authority _____________________________________________

Designation with Official Seal ________________________________________________

Full Name of Certifying Authority _____________________________________________

Office Address ____________________________________________________________

Office Phone No. _________________ Mobile No:_________________(optional)

ID No: ______________________________(optional)

Note: Photograph is to be attested by the certifying authority.

The Certifying Authority should preserve a duplicate copy of this Certificate.
 APPENDIX -3

PROFORMA b
Residential/Domicile Certificate for candidates not residing in the State of West Bengal
but whose parent(s) is (are) permanent resident(s) of West Bengal having their permanent
home address within West Bengal.
Certified that _____________________________________________

Father/ mother of ________________________________(the applicant) is/ are

permanent Resident of West Bengal at Village/House No. ___________________

Street _____________________________________________________________

Post Office _______________________Police Station _______________________

In the District of _____________________________

Under ____________________________ Assembly Constituency

Father’s/ Mother’s Signature

Paste 4 cmx3 cm
Paste 4 cmx3 cm
size recent colour
size recent colour
photograph of
photograph of the Candidate’s Signature
father/ mother of
candidate in this
the candidate in
box
this box
Candidate must sign here in front of
the certifying authority
(Candidate’s Photograph) (Father’s/ Mother’s Photograph)

Signature of Certifying Authority _____________________________________________

Designation with Official Seal ________________________________________________

Full Name of Certifying Authority _____________________________________________

Office Address ____________________________________________________________

Office Phone No. _________________ Mobile No:_________________(optional)

ID No: ______________________________(optional)

Note: Photographs are to be attested by the certifying authority.

The Certifying Authority should preserve a duplicate copy of this Certificate.
 APPENDIX – 4
Proforma for Income Certificate

Certified that the TOTAL ANNUAL FAMILY INCOME FROM ALL SOURCES of

________GUARDIAN____________, guardian of ____________CANDIDATE____________

residing at ________________________________Post Office _________________________

Police Station ______________ ___________in the district of ___________________________

in the state of West Bengal for the financial year 2021-2022 is less than Rs. 2.50 lakhs (Rupees

two lakhs and fifty thousand only) and stands at Rs. ____________________ (Rupees

________________ ___________________________).

Paste 4 cmx3 cm
size recent colour Candidate’s signature
photograph of the
candidate in this Candidate must sign here in front of the certifying
box authority

(Candidate’s Photograph)

Signature of Certifying Authority _____________________________________________

Designation with Official Seal ________________________________________________

Full Name of Certifying Authority _____________________________________________

Office Address ____________________________________________________________

Office Phone No. _________________ Mobile No:_________________(optional)

ID No: ______________________________(optional)

Note: Photographs are to be attested by the certifying authority.

The Certifying Authority should preserve a duplicate copy of this Certificate.
 APPENDIX-5
Certificate regarding physical limitation to write in an examination.
Certificate No. ……………………………… Dated …………… Paste 4 cmx3
cm size recent
This is to certify that Mr./Ms. ……………………………………………………………
colour
Son/daughter of Mr. Ms. ………………………………………………………………….. photograph of
Residing at ………………………………………………………..………………………………….. the candidate
in this box.
………………………………………………………………………………………………..
Having application No. ………………………………….……… has the following disability (name of the
Specified Disability) ………………………………………………………………………………………………. In
percentage of …………………………………………………(in words) ……………………………………..(in
figures).
Please tick the specified disability (Assessment may be done on the basis of Gazette of India,
Extraordinary, Part-II, Section-3, Subsection (ii)) Ministry of Social Justice and
Empowerment)
S. Category Type of Disability Specified Disability
No.
1 Physical Locomotor a) Leprosy cured person,
Disability Disability b) Cerebral palsy,
c) Dwarfism,
d) Muscular dystrophy,
e) Acid attack victims
Visual Impairment a) Blindness,
b) Low vision
Hearing Impairment a) Deaf,
b) Hard of hearing
Speech & Language a) Permanent disability arising out of conditions
Disability such as laryngectomy or aphasia affecting one
or more components of speech and language
due to organic or neurological causes
2 Intellectu a) Specific learning Disability (Perceptual
al Disabilities, Dyslexia, Dyscalculia, Dyspraxia &
Disability Development Aphasia)
b) Autism spectrum disorder
3 Mental a) Mental illness
Behaviour
4 Disability i. Chronic a) Multiple sclerosis
caused due Neurological b) Parkinsonism
to Conditions
ii.Blood disorder a) Haemophilia,
b) Thalassemia,
c) Sickle cell disease
5 Multiple a) More than one of the above specified
Disabilities disabilities including deaf blindness
This is to further certify that he /she has physical limitation which hampers his/her writing
capabilities to write the examination owing to his/her disability.
Signature
Name
Chief Medical Officer/ Civil Surgeon/Medical Superintendent
Govt. Health Care Institution with seal
 APPENDIX-6
Letter of Undertaking for Using Own Scribe

I……………………………………………………….., a candidate with…………………………………………………..

(Name of the disability) appearing for the ………………………………………………………………………………

(Name of the examination) bearing Application No. ……………………………………….. do hereby state

that …………………………………………………………………………………….. (Name of the scribe) will provide

the service of scribe/reader for the undersigned for taking the aforesaid examination.

I do hereby undertake that his qualification is ………………………………………….

Signature of the candidate Paste 4 cmx3

cm size recent
colour
Name of the scribe: …………………………………………………
photograph of
ID of the scribe: …………………………………………………………. the scribe in
ID number: this box.