Proformas for certificates JENPAS(UG) 2023

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 31.12.2022.
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 31-12-2022.

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.

Proformas for certificates JENPAS(UG) 2023

Proformas for certificates JENPAS(UG) 2023

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 31.12.2022.

Certified that ____________________________________________son / daughter of

____________________________________has passed the ‘10+2’ Examination in the year______ / will
appear in the Final ‘10+2’ Examination in 2023 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 31-12-2022.

Candidate’s signature

Paste 4 cmx3 cm
size recent colour Candidate must sign here in front of the certifying 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.

Proformas for certificates JENPAS(UG) 2023

Proformas for certificates JENPAS(UG) 2023

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
father/ mother of Candidate’s Signature
the candidate in
the candidate in
this box Candidate must sign here in front of
this box
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.

Proformas for certificates JENPAS(UG) 2023

Proformas for certificates JENPAS(UG) 2023

APPENDIX – 4

Certificate regarding physical limitation in a examinee to write

This is to certify that, I have examined Mr/Ms/Mrs

___________________________________________________________________________________(name of the candidate with disability), a person with

__________________________________________________________ (nature and percentage of disability as

mentioned in the certificate of disability), S/o/ D/o

________________________________________________________________________________________________,a resident

of___________________________________________________________________________________________________________

(Village/District/State) and to state that he/she has physical limitation which hampers his/her writing

capabilities owing to his/her disability.

Signature

Chief Medical Officer/Medical Superintendent of a Government health care institution

Name & Designation:

Name of Government Hospital/Health Care Centre with Seal:

Place:

Date:

Note:

Certificate should be given by a specialist of the relevant stream/disability

(e.g. ,Visual impairment - Ophthalmologist, Locomotor disability- Orthopaedic specialist/ PMR)

Proformas for certificates JENPAS(UG) 2023

Proformas for certificates JENPAS(UG) 2023

APPENDIX-5

Letter of Undertaking for Using Own Scribe

I _____________________________________________________________________, a candidate with

___________________________________________________________________________________(name of the

disability) appearing for the ____________________________________________________________ (name

of the examination) bearing Roll No. ______________________________________________________ at

_____________________________________________________________________________________________________(name

of the centre) in the District ____________________________________________,

______________________________________________________________________________________(name of the State).

My qualification is ______________________________________________________________________.

I do hereby state that _________________________________________________________________

(name of the scribe) will provide the service of scribe/reader/lab assistant for the

undersigned for taking the aforesaid examination.

I do hereby undertake that his qualification_______________________________________________.

In case, subsequently it is found that his qualification is not as declared by the undersigned

and is beyond my qualification, I shall forfeit my right to the admission and claims relating

thereto.

(Signature of the candidate with Disability)

Place:
Date:

Proformas for certificates JENPAS(UG) 2023