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Domicile Forms

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143 views3 pages

Domicile Forms

Uploaded by

chakravartisnehal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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WBJEE-2021 Information Bulletin Page: 28/47

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 31.12.2020.
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 31-12-2020.

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.
WBJEE-2021 Information Bulletin Page: 29/47

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 31.12.2020.

Certified that ____________________________________________son / daughter of


____________________________________has passed the ‘10+2’ Examination in the
year______ / will appear in the Final ‘10+2’ Examination in 2021 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 31-12-2020.

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.
WBJEE-2021 Information Bulletin Page: 30/47

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.

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