I

_____________________________________ son/daughter of Shri _________________________

resident of village/town/city __________________ district _________________ State

________________ hereby declare that I belong to the _______________________ community

which is recognized as a backward class by the Govt. of India for the purpose of reservation in

services as per orders contained in Deptt. of personnel and training Office Memorandum

No.36033/3/2004-Estt (Res) dated 9.3.2004. it is also declared that I do not belong to the

persons/sections (Creamy Layer) mentioned in Column 3 of the Schedule to the

above referred office Memorandum dated 9.3.2004.

(Signature of applicant