ANNEXURE TO APPLICATION FORM
PROFORMA TO BE FILLED BY OBC CANDIDATES
1. Name of candidate ___________________________________________
2. Roll No.
3. (a) Name of Father ___________________________________________
(b) Date of birth of Father ___________________________________________
4. (a) Name of Mother ___________________________________________
(b) Date of birth of Mother ___________________________________________
5. (a) Profession of Father ___________________________________________
(b) (i) If in service, whether he is/was working under ___________________________________________
Central Govt./State Govt./Public Sector
Undertaking/Autonomous Body/Private
Organisation or somewhere else.
(ii) If in service, name of the post to which he was appointed
by direct recruitment. ____________________________________________
(iii) Group of the post (viz. Group A, B, C or D) to ____________________________________________
which he was appointed by direct recruitment.
(iv) If posts in the organization are not classified as ____________________________________________
Group A, B, C or D, whether the post to which
your father was appointed by direct recruitment is
comparable or equivalent to any group A, B, C or
D post in Govt. If yes, to which it is comparable.
(v) Details of all the post held by Father
Name of the post and group of Pay Scale of the post Date of Appointment/ Age at the time of
the post & equivalent of post Promotion to the post appointment/promotion
(vi) Whether your father has/had been in employment____________________________________________
in any International Organisation like U.N., IMF,
World Bank. If yes, duration of such employment.
(vii) If father is deceased, date of his demise. ____________________________________________
(viii) If father suffers from permanent incapacitation,
date from which he was incapacitated.
____________________________________________
6. (a) Whether father of the candidate holds or has ever___________________________________________
held a Constitutional post.
(b) If yes, name of the post(s) and duration of holding____________________________________________
the post(s).
7. If father is/was in armed forces or in para military service,___________________________________________
the post which he is/was holding or held at the time of
retirement/leaving the job.
8. (a) Profession of Mother ___________________________________________
(b) (i) If in service, whether she is/was working under ___________________________________________
Central Govt./State Govt./Public Sector
Undertaking/Autonomous Body/Private
Organisation or Somewhere else.
(ii) If in service, name of the post to which she was appointed
by direct recruitment.
____________________________________________
(iii) Group of the post (viz. Group A, B, C or D) to____________________________________________
which she was appointed by direct recruitment.
(iv) If posts in the organization are not classified as____________________________________________
Group A, B, C or D, whether the post to which
the mother was appointed by direct recruitment is
comparable or equivalent to any group A, B, C or
D post in Govt. If yes, to which it is comparable.
(v) Details of all the posts held by Mother :-
Name of the post and group of Pay Scale of the post Date of Appointment/ Age at the time of
the post & equivalent of post Promotion to the post appointment/promotion
(vi) Whether your mother has/had been in employment____________________________________________
in any International Organisation like U.N., IMF,
World Bank. If yes, duration of such employment.
(vii) If mother is deceased, date of her demise. ____________________________________________
(viii) If mother suffers from permanent incapacitation,
date from which she was incapacitation.
___________________________________________
9. (a) Whether mother of the candidate holds or has ever____________________________________________
held a Constitutional post.
(b) If yes, name of the post(s) and duration of holding ____________________________________________
the post(s).
10. If mother is/was in armed forces or in para military service,
the post which she is/was holding or held at the time of
retirement/leaving the job. ____________________________________
11. (A) Whether the parents of the candidate own agricultural land. ___________________________________
(B)) If yes,
(a) Area of the irrigated land owned by father, mother and____________________________________
Children aggregated.
(b) Area of the unirrigated land owned by father, mother and ____________________________________
Children aggregated.
(c) Statutory ceiling limit of land hold at the place where____________________________________
land owned is located.
(d) If the land is both irrigated and unirrigated, indicate ____________________________________
whether condition given in clause (b)(i) of Schedule V
to the DoP&T O.M. No.36012/22/93-Estt.(CST), dated
8-9-1993 applies. Give detailed. ____________________________________
12. Annual income of father for last three years (year-wise)
(a) Income from salary ____________________________________
(b) Income from agriculture ____________________________________
(c) Income from other sources ____________________________________
(Note : Attach income-tax returns)
13. Annual income of mother for last three years (year-wise)
(a) Income from salary ____________________________________
(b) Income from agriculture ____________________________________
(c) Income from other sources ____________________________________
(Note : Attach income-tax returns)
14. (a) Details of wealth held by parents ____________________________________
(b) Whether the wealth held is within the exemption limit ____________________________________
as prescribed in Wealth Tax Act ?
15. Whether documentary proof in support of service/status/ ____________________________________
land holding /income from different sources property held by
parents have been attached ?
Information furnished above is true to the best of my knowledge and I have not concealed any relevant
information. I swear that if it is found at any stage that information furnished by me is false or that I have concealed
some relevant information, I will forfeit the claim to appointment to any service on the basis of Combined Medical
Services Examination, 2017.
Signature of the Candidate
Place ………………………
Date ……………………….
