HEADQUARTERS. OFFICEEMPL.OYEES' STATE INSURANCE

CORPORATIONPANCHDEEPBHAVAN: c.I.G. ROAD: NEWDELHI-110002 (ISO 9001-2000 Certified)

Website - www.esic.nic.in

DMC(ME)Fax: 011-23234537

Tale/Fax: 011-23234685E-Mail: dmc-dl@esic.nic.in

VOIP No: 10011079

No:L-ll/12/3/UG Admission/201S-16/MEC Date: 05.06.2015

ADMISSION NOTICEINVITATION OF APPLICATIONS FORADMISSION OF 'WARDS OF

INSURED PERSONS' (IPs) IN UG COURSE (MBBS) IN ESIC MEDICALCOLl.EGES FORACADEMIC SESSION 2015-16.

ESI Corporation, a statutory body established by an Act of Parliament, i.e. ESI

Act [Act No. 34] of 1948, under the administrative control of Ministry of Labour&

Employment, Govt. of India, has started Medical Education Institutions in the

country at large.

The Central Government has approved the admission policy and procedure for

under graduate (MBBSjBDS) Courses in ESIC Medical Education Institutions

(Annexure-I). It provides for ESIC Management Quota after allocation to

"All India Quota" and the "State Government Quota".

Applications are invited from 'Wards of Insured persons' under ESI

Scheme who have· qualified in 'All India Pre-MedicaI/Pre-Dental Entrance

Test, 2015' (AIPMIT - 2015) for admission to UG course (MBBS) in ESIC

Medical Colleges under "ESIC Management Ouota" for academic session

2015-16 as per admission policy and procedure approved by the

Government of India I ESI Corporation.

The Institution-wise details of seats provisionally to be allotted under"ESIC MANAGEMENT QUOTA" are as under

51. Name of E51 MledicalCollege Total UR SC 5T OBC PHNo No of @ @ @

Seats 15% 7.5% 27%1. Joka- Kolkata, West Bengal 52 26 08 04 14

2. Rajaji Nagar, Bangalore, Karnataka 45 24 07** 03 12

3. Gulbarga, Karnataka 45 23 06** 03 12 3%*4. K.K. Nagar, Chennai, Tamil Nadu 20 10 03 01** 06

Total 162 83 24 11 44*3% seats are reserved for P.H. category with 'Horizontal Reservation' across all

categories.

**Rounding off to match the model roster of reservation on All India basis by open

competition

The final number of seats to be allotted may be different from the

provisional number (of seats given above and would be subject to grant of

permission to admit fresh batch of students by the Central Government in

r/0 the above mentioned ESIC Medical Colleges.

Mechanism for filling up of E51CManagement Quota

.:. Available seats of 'TSIC Management Quota" in various States will be pooled on

'All India Basis' and allotted, amongst the wards of Insured persons (IPs) .

•:. The 'guiding principles' for filling up of ESIC Management Quota will be as

under:-

• The ESIC Management Quota seats will be filled on merit cum preference

basis.

• Reservation policy of Central Government for SCjSTjQBCjPH etc. will be

followed for allotment of seats

• Candidates seeking admission under 'ESIC Management Quota' will have to

fulfill the following eligibilitv criteria:

• Minimum eligibility criteria for admission will be as per MeI regulations.

®

• The selection and admission to MBBS seats in any Medical Institution

recognized for running MBBS Courses as per Indian Medical Council Act

1956 is subject to fulfilling the admission criteria, eligibility, medical fitness

and such other criteria as may be prescribed by the Universities etc.

In event of any difference in criteria of MCI and Affiliating University etc.,•the higher criteria will prevail.

• Applicants are advised to refer to the websites of the Affiliating

Universities, i.e. Rajiv Gandhi University of Health Sciences (RGUHS) for

ESIC colleges in Karnataka; West Bengal University of Health Sciences

(WBUHS) for ESIC colleges in West Bengal and The Tamil Nadu Dr. MGR

Medical University (TNMGRMU) for ESIC colleges in Tamil Nadu, for further

information.

• Application must be accompanied by "Ward of Insured Person"

Certificate, issued by concerned Regional DirectorlSRO I/C.[Annexure .- II]

• Candidates will be allotted seats, based on their category and merit cum

preference of Institution, through a centralized counseling to be conducted by

ESIC in Delhi for the ESIC Management Quota as per schedule provided.

• The venue and other details for the counseling will be posted on the web-site

in due course. Candidates are requested to check the web-site

regularly for further details.

HOW TO APPLY

Candidates may submit application in the prescribed format (Annexure - III) with

copies of required certificates and Affidavits (Annexure - IV) well in time so as to reach

ESIC Hqrs. Office latest by 5 pm on 6th July, 2015. ESIC will not be responsible for

any delay, postal or otherwise,

The application may be sent to

Director General

"Panchdeep Bhawan", ESI Corporation HQ Office,

C.I.G. Marg, New [)elhi-110002

The envelope may be marked as under

APPLICATION FOR ADMISSION OF 'WARDS OF INSURED PERSONS' (IPs) INUG COURSE(MBBS) IN ESlICMEDICAL COLLEGES(2015-16).

KIND ATTN: Dy. Med. Comm. (ME-II)

To,Director General"Panchdeep Bhawan", ESI Corporation HQ Office, C.I.G. Marg,New Delhi-ll0002

From: XVZ

Important dates in the process of admission are as given below:-(tentative)

1- Last date for receipt of Applications at ESIC HQ, New Up to 5 pm onDelhi 6th July, 2015

2- Display of Provisional List of eligible candidates called 16th July, 2015for counseling3- 1st Counseling & Allocation of College & deposit of fee 30th & 31st July 20154- 2nd Counseling, if required 18th August, 2015

OTHER IMPORTANT INSTRUCTIONS

1. Fee structure Stil)ulation on annual basis:Tuition Fee Rs 24,OOO/-(Rs.Twenty four thousand only) per annum

University Charges As per Actual

College Security Deposit Rs 5000/- (Five thousand only) per annum i.e.

(Refundable) chargeable annually

Hostel Charges To be decided separately

Hostel and Mess Security To be decided separately

Mess Charges As per actual

Note: As the MBBS Course is 4 '12 years Course, The tuition fee to be charged for

the final year will be half of the Annual Tuition Fee.

Demand Draft (DO) of Rs. 24000/- drawn in favor of 'ESI Fund Account No.1',payable at New IJlelhi, shall have to be deposited at the counseling venue,

immediately (on the same day) after allotment of seat. The amount shall be

refunded after deduction of Rs.1000/- if the seat is surrendered within 03 days of

allotment. The amount will be forfeited if the student who is allotted the seat does

not join the course within the stipulated time, which would be mentioned in the

'Letter of Allotment' of seat

There will be no capitation fee or profiteering in any form.

2. Counseling for Allcltment2.1 Candidate should bring the following documents in original along with self-

attested copies for verification failing which they will not be allowed to

participate in the counseling process

2.1.1 Secondary School Certificate which must bear Date of Birth or

Birth Certificate.

2.1.2 Senior Secondary School certificate (+2). Provisional if final has

not been issued.

2.1.3 Admit card for All India Pre-Medical/Pre Dental Entrance Test -

201S (AIPMT-2015)

2.1.4 Scone card (AIPMT-2015) with Rank Position i.e. All India Rank

2.1.5 'Ward of Insured Person' Certificate from Competent Authority.

2.1.6 SCjST Certificate in prescribed format (Annexure - V)

2.1.7 OBC Certificate in prescribed format (Annexure - VI)

2.1.8 Physically Handicapped Certificate from 'Appropriate Authority' as

specified by the concerned StatejUT Government (Annexure -

VII) subject to verification by Competent ESIC Board, if required.

2.1.9 For IFEMALECANDIDATES ONLY

2.1.9.1 Affidavit by candidate as per Annexure - VIII

2.1.9.2 Affidavit by IP as per Annexure - IX

2.2 Option once exercised during counselling will be final and cannot be

changed.

2.3 Candidates who fail to attend the counselling at the specified date and time

will forfeit their right to counselling and admission and their name will not

be considered later.

2.4 If the candidate is absent during the 1st phase of counselling for which he j

she is called, he j she will not be eligible to attend the 2nd phase of

Counselling, if conducted.

3. Ref: Para 3 of Anm~xure- I - 'ESIC Management Quota' - Wards of Insured

Persons from anywhere in India are eligible to apply for these seats and seats shall

be allotted based on All India merit cum preference basis, following counseling by

ESIC Selection committee constituted by Competent Authority.

®

4. Execution of Bond for Service - ref para 7 of Annexure - I

5. Insured person for the purpose of availing benefit of ESIC Management Quota

- ref para 8 of Annexure - I

6. 'Ward of Insured Person' - ref para 9 of Annexure - I

7. "The selection of students for the year 2015-16 in ESIC run MedicalColleges is subject to the result of the WP 12953 of 2015, filed by M.Muhuvel and Others Vs Union of India & Others in the High Court ofJudicature at Madras".

Oy. Med. Comma(ME-II)For Director General

ANNEXURE-I

ADMISSION POLICY' FOR UNDER GRADUATE (MBBS/BDS) ADMISSIONS

Admission procedure for under graduate courses (MBBS and BDS) in ESIC

Medical Education institutions shall be as follows:

1. All India Ouota: 'All India Quota' will be 15% of total available seats in each of

its Medical Institutions, Or, All India Quota will be as per the prevailing Central

Government's [i.e. ~1inistryof H & FW] directives for the said quota, from time to

time. It will be filled up as per policy, including reservation policy, and procedures

of the Central Government.

2. State Government C~: Based on the location of the ESI's Medical Education

Institution, a 'State Government Quota' will be as per the policy of respective States

applicable to un-aided non-minority Institutions, or in the absence thereof, as may be

mutually agreed to, between the respective State Government and the ESI

Corporation from time to time. The Admissionsto these seats will be made according

to the policy, including reservation policy, and procedures of the State Government

concerned, and these seats will be filled up accordingly.

3. 'ESIC Management ()uota' The remaining seats after allocation to All India Quota

and the State Govt. Quota shall be treated as "ESIC Management Quota". It shall

comprise of seats 'pooled' together on All India basis from various ESIC

Medical/Dental Colleges, as the case may be. The seats shall be allotted to the

'Wards of Insured Persons' (IPs) on All India basis and shall be filled-up through

merit cum preference basis, following due process specified below or as may be

specified by ESICfrom time to time.

4. Methodology for filling up of ESIC Management Quota:-Available seats of

"ESIC Management Quota" in various States will be pooled on 'All India Basis' and

allotted, among the wards of Insured persons (IPs). The 'guiding principles' for

filling up of ESIC Management will be as under:-

4.1 The ESIC Management Quota seats will be filled through merit cum

preference basis.

4.2 Reservation policy of the Central Government will be followed, within the

ESIC Management Quota enumerated above.

4.3 Candidates seeking admission under 'ESIC Management Quota' will have

to fulfill the faUawing eligibility criteria:

4.3.1 Minimum eligibility criteria for adrnlsslon will be as per MCI

regulations

4.3.2 Submit "Ward of Insured Person" certificate issued by Competent/

deslqnated Authority for the purpose by ESIC.

4.4 Prospective/desirous and eligible candidates will be required to appear in

an All India competitive examinations in force or any other similar

equivalent approved Central entrance test as may be specified from time

to time by ESIC.

4.5 After qualifying in such Centralized test, candidates will have to respond

to the advertisement by the ESIC and, apply for admission under the

ESIC Manaqement Quota, along with the marks / merit obtained in the

said Centralized Entrance Test, their preference and supportive

documents, etc.

4.6 ESIC will then prepare a merit list based on the rank /rnarks of eligible

applicants in the specified test/merit list for the year, consistent with the

reservation policy of the Central Government for preparation of category-

wise inter-se merit.

4.7 Candidates will be allotted the seats, based on their merit cum

preference of Institution and category, through a centralized counseling

to be conducted by ESIC for the ESIC Management Quota.

5. Unfilled/Un-allotted seats, if any, after the specified cut-off date, will be

surrendered to the respective State Government as per the time schedule given

by the regulatory body, i.e. of Medical j Dental Council of India (MCIjDCI), for

inclusion in the State Government Quota, to be filled up as per policy, including

reservation policy, and proceduresof the State Government.

6. Fee structure Stipulation:

Fee structure (Tuition fee & other approved fee) in ESIC Medical Education

Institutions will be as may be approved by ESICfrom time to time. There will be

no capitation fee or profiteering in any form.

7. Execution of Bond for Service

All Candidates seeking admission to any ESICMedical Education Institution will

have to execute a bond, to serve any ESICj ESI Scheme (ESIS institution run by

State Government) for a period of 5 years, as may be specified, from time to

time. Period of rural service, if any, as per policy of the Central or State

Government. will be inclusive in the five year period of the bond,

8. Insured person for the purpose of availing benefit ESIC Management Quota

for his j her wards shall be, as under

"The 'Insured Person' shall be an 'employee' as defined in the ESIAct' and

he/she should have been in continuous insurable employment for a minimum

period of five years as on 1st January of the year of admission and should have

paid at least 78 days of contribution in each Contribution Period, during this five

year period. The5year period would be counted from the date of entry into the

ESIScheme, For employees who entered the Schemeprior to gh June, 2011, the

date of entry into the Scheme for the purpose of availing benefit of ESIC

management quota for his/her wards would be the date of submission of

'DeclarationForm' by the employer in respect of the employee concerned at the

Branch Office or another appropriate office of the ESIC For employees who

entered the Scheme after gh June, 2011, the date of entry into the Scheme for

the above purpose would be the date of registration available in the IP database

of the ESIC In case there is default or delay on the part of the employer in

getting itself or the concerned employee covered under the Scheme, the ESIC

will not be responsible for the said default or delay, Any period prior to the date

of entry described above would not be counted towards the 05 year period of

eligibility for the purpose of availing benefit of ESICManagement Quota./I

9. 'Ward of Insured Person'will be a legitimate natura! born child who is who/Iv

deoendent on the_earnings of the insured person and who is -

(i) receiving education till he or she attains the age oftwentv-one vears.

(ii) or an unmarried legitimate natura! born daughter.

10. Regional Director/Other Officer/Authority/Committee under ESIC as may be

specified by ESIC from time to time shall be the Competent Authority to issue the

"Ward of Insured Person" certificate

Annexure - IIPhoto of

'Ward of lP'duly Attestedby ROllO trc

Photo of lPduly Attestedby ROllO lIe'Ward of Insured Person' CIP) - CERTIFICATE

(To be issued on OFFICIAL LETTERHEAD)

This is to certify that Son/Daughter/Ward of ShrijSmt Insurance No:_________ is 'Ward of Insured person' as per records.

Insurance No: Son / Daughter /is a resident of VillagejTaluk

_______ Distt State .and has been

ShrijSmt _Wife of

in continuous insurable Employment of (Full address of the Shop/Establishment withEmployers Code No.) for a period of five years, as on 01/01/2015,and contributions have' been paid for at least 78 days in each contributionperiod mentioned below, during this five year period as per record with detailsasunder.

S. No. Contribution periods for academic session Contribution paid for -2015-16 No. of days

l. 1st April, 2010 - 30th September, 20102. 1st October, :2010 - 31st March, 20113. 1st April, 2011- so" September, 20114. 1st October, :2011 - 31st March, 20125. 1st April, 2012 - 30th September, 20126. 1st October, :2012- 31st March, 20137. 1st April, 2013 - 30th September, 20138. 1st October, :2013 - 31st March, 20149. 1st April, 2014 - so" September, 2014

This certificate is being issued on the basis of Verification of records by ShrijSmt.designation at

RegionaljSRO Office for eligibility under "ESICManagement Quota" for admission to Undergraduate course, i.e. MBBS in ESIC MedicalColleges for the Academic Session 2015-16.

DATE

PLACE

REGIONAL DIRECTOR ISRO lIe

(Duly stamped)

ANNEXURE-III

APPLICATION FORMAT FOR 'WARD OF IP' FOR ADMISSION IN ESIC MEDICALCOLLEGEFOR UG COURSES (MBBS) UNDER 'ESIC MANAGEMENT OUOTA' FORACADEMIC SESSION 2015-16

1. NAME

2. FATHER'S NAME

3. MOTHER'S NAMESelf Attested

4. DATE OF BIRTHPHOTOGRAPH

5. SEX

6. CATEGORY-GENjSCjST JOBCjPH(Specify any other)

7. CORRESPONDENCEADDRESS

8. PERMANANENT ADDRESS

9. Contact No.

10. E-mail address

11. INSURANCE NO. OF IP

12. RELATIONSHIP WDH IP

EDUCATION YROF13. BOARD SUBJECTS

QUALIFICATION PASSING

13.1 SECONDARY SCHOOL(10TH

)

13.2 SENIOR SECONDARY (+2)

DETAILS of Roll No. Score Rank -All India14. QUALIFYING EXAM, i.e.

AIPMT- 2015

@

ANNEXURE-III cont .....

PREFERENCEOF ESIC 1.MEDICAL COLLEGE FORADMISSION TO UG 2.

15. COURSE, i.e. MBBS, FOR 3.ACADEMIC SESSION 2015-16. 4.

Signature of IP Signature of the Candidate

XXXXXXXXXXXXXXX)(xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

ANNEXURE-IV

List of Enclosures

(All copies to be self - attested)

1. Copy of - School Certificate for proof of Date of Birth

2. Copy of - Senior Secondary School certificate (+2). Provisional

if final has not been issued

3. Copy of admit card for AIPMT-2015

4. Copy of score card (AIPMT-2015) with Rank Position i.e. All

India Rank

5. Copy of - Ward of IP Certificate from Competent Authority.

6. Copy of SC/ST IOBCIPH Certificate from the 'Appropriate

Authority' as specified by the concerned State/UT Government

(Annexures Vi VI; and VII)

7. Copy of A,ffldavits at Annexure - VIII & IX (if applicable)

@

APPEND lX-I

(A) The form of certificate to be produced by ScheduledCastes and Scheduled Tribes candidates applying forappointment to posts under the Government of India.

This is to certify that Shri/ShrimatilKumari* ........................... son/daughter* of .of village/town* in District!Division* of the State/UnionTerritory* belongs to the .caste/tribe* which is recognised as a Scheduled CastelScheduled Tribe* under :-

the Constitution (Scheduled Castes) Order, 1950@.

the Constitution (Scheduled Tribes) Order, 1950@.

the Constitution (Scheduled Castes) Union Territories Order,1951@.

the Constitution (Scheduled Tribes) Union Territories Order,1951@.

[as amended by the Scheduled Castes and Scheduled TribesList (Modification) Order, 1956; the Bombay ReorganisationAct, 1960, the Punjab Reorganisation Act, 1966, the State ofHi machal Pradesh Act, 1970, the North Eastern Areas(Reorganisation) Act, 1971, the Scheduled Castes andScheduled Tribes Order (Amendment) Act, 1976., the State ofMizoram Act, 1986, the State of Arunachal Pradesh Act, 1986and the Goa, Daman and Diu (Reorganisation) Act, 1987.]

the Constitution (Jammu and Kashmir) Scheduled CastesOrder, 1956@.

the Constitution (Andaman and Nicobar Islands) ScheduledTribes Order, 1959 as amended by the Scheduled Castes andScheduled Tribes Order (Amendment) Act, 1976. @

the Constitution (Dadar and Nagar Haveli) Scheduled CastesOrder, 1962.@

the Constitution (Dadar and Nagar Haveli) Scheduled TribesOrder, 1962.@

the Constitution (Pondicherry) Scheduled Castes Order,1964.@

the Constitution (Uttar Pradesh) Scheduled Tribes Order,1967.@

the Constitution (Goa, Daman and Diu) Scheduled CastesOrder, 1968.@

the Constitution (Goa, Daman and Diu) Scheduled TribesOrder, 1968.@

the Constitution (Nagai and) 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) Order (Amendment) Act, 1990.@

the Constitution (ST) Order (Amendment) Act, 1991.@

the Constitution (ST) Order (Second Amendment) Act, 1991.@

the Scheduled Castes and Scheduled Tribes Orders(Amendment) Act 2002@

the Constitution (Scheduled Castes) Order (Amendment) Act,2002@

the Constitution (Scheduled Castes and Scheduled Tribes)Orders (Amendment) Act, 2002 @

The Constitution (Scheduled Castes) Orders (SecondAmendment) Act, 2002@

% 2. Applicable in the case of Scheduled Castes/ScheduledTribes persons who have migrated from one State/UnionTerritory Administration to another.

This certificate is issued on the basis ofthe Scheduled Castes/Scheduled Tribes certificate issued to Shri/Shrimati* .

....................................... Father/Mother of Shri/Shrimati/Kumari of village/town*.......................................... in DistrictiDivision* .of the State/Union Territory* who belongs tothe caste/tribe* which is recognised as a Scheduled CastelScheduled Tribe in the State/Union Territory* of .................... '" issued by the .

dated .

% 3. Shri/Shrimati/Kumari*and/or* his/her* family ordinarily reside(s) in village/town* of District!Division*of the State/Union Territory* of.. .

Signature .

Name .

**Designation with Stamp .

(With Seal ofOffice)State/Union Territory*

Place: .

Date: .

*Please delete the words which are not applicable.

@Pleasequote specific Presidential Order.

% Delete the paragraph which is not applicable.

NOTE: The term "ordinarily reside (s)" used here will havethe same meaning as in Section 20 of theRepresentation of the People Act, 1950.

**List of authorities empowered to issue ScheduledCaste/Scheduled Tribe/OBC Certificates.

(i) District Magistrate/Additional District Magistrate/CollectorlDeputy Commissioner/Additional DeputyCommissioner/Deputy Collectorll st Class StipendiaryMagistrate/] Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner.

tenot below of the rank of I st Class StipendiaryMagistrate).

(ii) Chief Presidency Magistrate/Additional ChiefPresidency Magistrate/Presidency Magistrate.

(iii) Revenue Officers not below the rank ofTehsildar.

(iv) Sub Divisional Officer of the area where the candidateand/or hislher family normally resides.

(8) The form of certificate to be produced by OtherBackward Classes candidates applying for appointment toposts under the Government of India.

This is to certify that Shri/Shrimati/Kumari* ............................. son/daughter* of Shri ofvillage/town* in DistrictiDivision* ofthe State/Union Territory* belongs to the.................... Community which is recognised as a backwardclass under:

@ Government of India, Ministry of Welfare ResolutionNo. 12011/68/93-BCC (C) dated 10th September, 1993 publishedin the Gazette oflndia Extraordinary Part-I, Section-I, No. 186dated 13th September, 1993.

@ Government of India, Ministry of Welfare ResolutionNo. 120 11/9/94-BCC dated [9-10-94, published in the Gazetteof India Extraordinary Part-I, Section-I, No. 163 dated20-10-1994.

@ Government of India, Ministry of Welfare ResolutionNo. 120 11/7/9S-BCC dated 24-S-9S, published in the Gazette ofIndia Extraordinary Part-I, Section- l , No. 88 dated2S-S-199S.

@ Government of India, Ministry of WeIfare ResolutionNo. 120 11/96/94-BCC dated 9th March, 1996 published in theGazette oflndia Extraordinary Part-I, Section-I, No. 60 dated11th March,1996.

@ Government of India, Ministry of Welfare ResolutionNo. 120 II /44/96-BCC dated 6th Dece ber, [996 published inthe Gazette of India Extraordinary Part-I, Section-I, No.2 10dated II th December, 1996.

@ Government of India, Ministry of WeIfare ResolutionNo. 12011/99/94-BCC dated II th December, 1997 published inthe Gazette of India Extraordinary Part-I, Section-I, No. 236dated 12th December, 1997.

@ Government of India, Ministry of Wel fare ResolutionNo. 12011/13/97-BCC dated 3rd December, 1997 published inthe Gazette oflndia Extraordinary Part-I, Section-I, No. 239dated 17th December, 1997.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 11/68/98-BCC dated the 27thOctober, [999 published in the Gazett . oflndia ExtraordinaryPart-I, Section- l , No. 241 dated the 27th October, 1999.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12011/88/98-BCC dated 6thDecember, 1999 published in the Gazette of India ExtraordinaryPart-I, Section-I, No. 270 dated 6th December, 1999.

2

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12011/36/99-BCC dated 4th April,2000 published in the Gazette of India Extraordinary Part-I,Section-I, No. 71 dated 4th April, 2000.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 11/44/99-BCC dated the 21stSeptember, 2000 published in the Gazette oflndia ExtraordinaryPart-I, Section-I, No. 210 dated the 21 st September, 2000.

@ Government oflndia, Ministry of Social Justice andEmpowerment Resolution No. I20IS/9/2000-BCC dated 6thSeptember, 200 I published in the Gazette of India ExtraordinaryPart-I, Section-I, No. 246 dated 6th September, 2001.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 1201111/2001-BCC dated19th June, 2003 published in the Gazette of IndiaExtraordinary Part-I, Section, I No. ISI dated 20th June, 2003.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12011/4/2002-BCC dated 13thJanuary, 2004 published in the Gazette of India Extraordinary,Part-I Section-I, No.9 dated 13th January, 2004.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12011114/2004-BCC dated 12thMarch, 2007 published in the Gazette oflndia Extraordinary,Part-I, Section-I, No. 67 dated 12th March, 2007.

@ Government oflndia, Ministry of Social Justice andEmpowerment Resolution No. 120 IS/2/2007-BCC dated 18thAugust, 2010 published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No. 232 dated 18thAugust,2010.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120IS/2/2007-BCC dated 11thOctober, 20 I0 published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No. 274 dated 12thOctober,2010.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 ISI1 S/2008-BCC dated 16th

June, 20 II published in the Gazette of India Extraordinary,Part-I, Section-I, No. -123 dated 16thJune, 20 II.

@ Government oflndia, Ministry of Social Justice andEmpowerment Resolution No. 120IS/13/2010-BC-II dated gIhDecember, 20 II published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No.-257 dated 8th December,2011.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. [20[S/OS/201 [-BC-II dated [~February, 2014 published in the Gazette of IndiaExtraordinary, Part-I, Section-!, No.4! dated 17th February,2014.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 200 12/ I29/2009-8C-JI dated 411

March, 2014 published in the Gazette oflndia Extraordinary,Part-I, Section-I, NoA53 dated 4th March, 2014.

(8) The form of certificate to be produced by OtherBackward Classes candidates applying for appointment toposts under the Government of India.

This is to certify that Shri/Shrimati/Kumari* ............................. sonldaughter* of Shri ofvillageltown* in Distric:t1Division* ofthe State/Union Territory* " belongs to the.................... Community which is recognised as a backwardclass under:

@ Government oflndia, Ministry of Welfare ResolutionNo. 12011I68/93-8CC (C) dated 10th September, 1993 publishedin the Gazette oflndia Extraordinary Part-I, Section-I, No. 186dated 13th September, 1993.

@ Government of India, Ministry of Welfare ResolutionNo. 120 11/9/94-BCC dated 19-10-94, published in the Gazetteof India Extraordinary Part-I, Section-I, No. 163 dated20-10-1994.

@ Government of India, Ministry of Welfare ResolutionNo. 12011/7/95-BCC dated 24-5-95, published in the Gazette ofIndia Extraordinary Part-I, Section-I, o. 88 dated25-5-1995.

@ Government of India, Ministry of Wel fare ResolutionNo. 120 11I96/94-BCC dated 9th March, 1996 published in theGazette oflndia Extraordinary Part-I, Section-I, No. 60 dated11th March,1996.

@ Government oflndia, Ministry of Welfare ResolutionNo. 120 II /44/96-8CC dated 6th December, 1996 published inthe Gazette of India Extraordinary Part-I, Section-I, No. 210dated II th December, I996.

@ Government oflndia, Ministry of Welfare ResolutionNO.12011l99194-8CCdated I lthDece ber,1997publishedinthe Gazette oflndia Extraordinary Part-I, Section-I, No. 236dated 12th December, 1997.

@ Government oflndia, Ministry of WeIfare ResolutionNo. 12011/l3/97-8CC dated 3rd December, 1997 published inthe Gazette of India Extraordinary Part-I, Section-I, No. 239dated 17th December, 1997.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 11/68/98-8CC dated the 27thOctober, 1999 published in the Gazette oflndia ExtraordinaryPart-I, Section-I, No. 241 dated the 27th October, I999.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12011/88/98-8CC dated 6thDecember, 1999 published in the Gazette of India ExtraordinaryPart-I, Section-I, No. 270 dated 6th December, 1999.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120I 1/36/99-BCC dated 4th April,2000 published in the Gazette of India Extraordinary Part-I,Section-I, No. 71 dated 4th April, 2000.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 11I44/99-BCC dated the 21stSeptember, 2000 published in the Gazette of India ExtraordinaryPart-I, Section-I, No. 210 dated the 21 st September, 2000.

@ Government oflndia, Ministry of Social Justice andEmpowerment Resolution No. 120 15/9/2000-8CC dated 6thSeptember, 200 I published in the Gazette oflndia ExtraordinaryPart-I, Section-I, No. 246 dated 6th September, 200 I.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12011/1/2001-8CC dated19th June, 2003 published in the Gazette of IndiaExtraordinary Part-I, Section, I No. 151 dated 20th June, 2003.

@ Government oflndia, Ministry of Social Justice andEmpowerment Resolution No. 12011/4/2002-8CC dated 13thJanuary, 2004 published in the Gazette oflndia Extraordinary,Part-I Section-I, No.9 dated 13th January, 2004.

@Governmentoflndia, Ministry of Social Justice andEmpowerment Resolution No. 12011/14/2004-BCC dated 12thMarch, 2007 published in the Gazette oflndia Extraordinary,Part-I, Section-I, No. 67 dated 12th March, 2007.

@Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 15/2/2007-8CC dated 18thAugust, 20 I0 published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No. 232 dated 18thAugust,2010.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12015/2/2007 -BCC dated 11thOctober, 20 10 published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No. 274 dated 12thOctober,2010.

@ Government oflndia, Ministry of Social Justice andEmpowerment Resolution No. 120 15/15/2008-BCC dated 16th

June, 20 II published in the Gazette of India Extraordinary,Part-I, Section-I, No. -123dated 16th June, 2011.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 120 15/l3/20 IO-BC-II dated gIhDecember, 20 II published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No.-257 dated 8th December,2011.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 12015/05/2011-8C-II dated I~February, 2014 published in the Gazette of IndiaExtraordinary, Part-I, Section-I, No.41 dated 17th February,2014.

@ Government of India, Ministry of Social Justice andEmpowerment Resolution No. 20012/l29/2009-BC-1I dated 4"March, 2014 published in the Gazette of India Extraordinary,Part-I, Section-I, NoAi3 dated 4th March, 2014.

@

Shri/Shrimati/Kumari * 'and/or*

his/her" family ordinarily reside(s) in village/town* ............. of District/Division" ofthe State/ UnionTerritory* of .

This is also to certify that he/she* does not belong tothe persons/sections* (Creamy Layer) mentioned in column 3of the Schedule to the Government of India, Department ofPersonnel & Training O.M. No. 360 12/22/93-Estt(SCT) dated8-9-1993 O.M. No. 36033/3/2004-Estt.(Res.) dated 9th March,2004, O.M. No. 36033/3/2004-Estt.(Res.) dated 14thOctober,2008 and O.M. No. 36033/1/2013-Estt.(Res.) dated 27th May 20 13.

Signature .

**Designation .

(with seal of Office)State/Union Territory

Place .

Date .

*Please delete the words which are not applicable.@ Strike out whichever is not applicable.

NOTE: The term "ordinarily reside(s)" used here will havethe same meaning as in Section 20 of theRepresentation ofthe People Act, 1950.

** Authorities empowered to issue Other BackwardClasses certificates will be the same as thoseempowered to issue Scheduled Caste/ScheduledTribe certificates.

Notel: Candidates claiming to belong to OBCs shouldnote that the name of their caste (including its spellings) asindicated in their certificates, should be exactly the same aspublished in the lists notified by the Central Government fromtime to time. A certificate containing any variation in the castename will not be accepted.

Note 2 :The OBC claim of a candidate will be determinedin relation to the State (or part of the State) to which his/herfather originally belongs. A candidate who has migrated fromone State (or part of the State) to another should, therefore,produce an OBC certificate which should have been issued tohimlher based on his/her father's OBC certificate from theState to which he (father) originally belongs .

Note 3 : No change in the community status alreadyindicated by a candidate in his/her simplified application formfor this examination will ordinarily be allowed by theCommission.

(B-1) The format of undertaking to be furnished

Along with the DAF by Other Backward Class candidatesapplying for appointment to posts under the Government ofIndia.

6

UNDERTAKING

1. son/daughter of

Shri resident of Village/Town/City District. StatelUT

................................ hereby declare that I belong to the

. community which is recognizedas a backward class by the Government of India for thepurpose of reservation in services as per orders contained inDepartment of Personnel & Training Office memorandumNo. 360 12/22/93-Estt(SCT) dated 8.9.1993. it is alsodeclared that I do not belong to persons/sections (CreamyLayer) mentioned in Column 3 of the Schedule to the abovereferred Office Memorandum, dated 8.9. 1993, O.M. No.36033/3/2004-estt.(Res) dated 9th March, 2004, O.M. No.36033/3/2004-Estt.(Res) dated 14thOctober, 2008 and O.M.No. 36033/1/20 13-Estt.(Res.) dated 27th May, 2013.

ANNFxutl!- Vii-Perform a-V

The form of certificate to be produced by Physically Handicapped candidates applyingfor appointment to posts under the Government of India.

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL

Certificate No . Date: .

DISABILITY CERTIFICATE

Recent Photograph ofthe candidate showingthe disability dulyattested by theChai rperson of theMedical Board

This is certified that Shri/Smt.lKum son/wife/daughter of Shri......................................... age sex identification mark(s) issuffering from permanent disability of following category:

A. Locomotor or Cerebral Palsy:

(i) BL-Both legs affected but not arms

(ii) BA-Both arms affected (a) Impaired reach(b) Weakness of gri p

(iii) BLA-Both legs and both arms affected

(iv) OL-One leg affected (right or left) (a) Impaired reach(b) Weakness of gri p(c) Ataxic

(v) OA-One arm affected (a) Impaired reach(b) Weakness of gri p(c) Ataxic

(vi) BH-Stiffback and hips (cannot sit or stoop)

(vii) MW-Muscular weakness and limited physical endurance.

B. Blindness or Low Vision:

(i) B-Blind

(ii) PB-Partially blind

C. Hearing impairment:

(i) O-Deaf

(ii) PO-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................ years months. *

3. Percentage of disability in his/her case is Per cent.

4. Shri/Smt.lKum meets the following physical requirementsfor discharge of his/her duties:-

(i)(ii)(iii)(iv)(v)(vi)(vii)(viii)(ix)(x)(xi)

F-Can perform work by manipulating with fingers.PP-Can perform work by pulling and pushing.L-Can perform work by lifting.KC-Can perform work by kneeling and crouching.B-Can perform work by bending.S-Can perform work by sitting.ST-Can perform work by standing.W-Can perform work by walking.SE-Can perform work by seeing.H-Can perform work by hearing/speaking.RW-Can perform work by reading and writing.

(Dr )Member

Medical Board

(Dr. )Member

Medical Board

Yes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/NoYes/No

(Dr )Chairman

Medical Board

Countersigned by the MedicalSuperintendentiCMOlHead of Hospital

(With seal)

* Strike out whichever is not applicable.

@

ANNEXURE - VIII

AFFl[DAVIT (By Female Candidate only)

1. That deponent Ms , aged years is the Daughter of

Shri. .

2. Shri......................... is employed with the factory / establishment,

viz covered under ESIAct vide Code No .

3. The father/mother of the deponent is beneficiary under the ESI Act having Insurance

no .

4. The deponent is unmarried.

5. The deponent hereby declares that aforesaid facts are correct on the basis of the

record and if the aforesaid declaration is found to be incorrect and contrary to the

records, the admission sought shall be declared illegal and liable to be cancelled.

6. The deponent further declares that if the information submitted by the deponent is

found to be incorrect the deponent would be liable to be prosecuted in accordance

with law.

DEPONENT

VERIFICATION:

I swear by this Affidavit that the contents of my above affidavit are true and correct to

my knowledge and belief. No part of it is false and nothing relevant has been concealed

therein.

Verified at on this day of. , 2015.

DEPONENT

[To be duly Notarized]

ANNEXURE -IXAFFIDAVIT

(By 11f) - only in case of female candidate)

1. That deponent is an employee with the factory/establishment,

viz..................................... covered under ESI Act vide Code

No .The deponent is a beneflclary under ESI Act. having Insurance

No .

2. The deponent has got Daughter (Name: ) is years of age.

3. The Daughter (Name: ) of the deponent is unmarried.

4. The deponent hereby declares that aforesaid facts are correct on the basis of the

record and if the aforesaid declaration are found to be incorrect and contrary to

the records, the admission sought shall be declared illegal and liable to be

cancelled.

5. The deponent further declares that if the information submitted with the deponent

is found to be incorrect the deponent would be liable to be prosecuted and face

the consequential action which the ESICorporation may deem fit and proper.

DEPONENT

VERIFICATION

I swear by this Affidavit that the contents of my above affidavit are true and

correct to my knowledge and belief. No part of it is false and nothing relevant has been

concealedtherein.

Verified at on this day of 2015.

DEPONENT

[To be duly Notarized]