Domicile 2024 1

PROFORMA FOR RESIDENTIAL/DOMICILE CERTIFICATE
PROFORMA A-1
Applicable for candidates residing in the State of West Bengal continuously at least for last ten (10) years as on
01.12.2023
To be issued by authorized persons other than Head of the Institution from which the candidate appeared/is due to
appear in 10+2 or equivalent examination.
Domicile Certificate: Type A-I
Certified that __________________________________________________ son/daughter of

_______________________________________________ is a resident / permanent resident of West Bengal at Village
/ House no.___________________________________________________________ street
___________________________________________________ P.O. ______________________ P.S.
___________________________ 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 years as on 01.12.2023.
Paste Passport size Note

photograph of applicant
in this box. Photograph is to be attested by the Certifying
Authority.
Signature of Certifying Authority :
Designation with Official Seal :
Full name of Certifying Authority :
Address :
Phone No. : Mobile No. :
ID No.
Note : The Certifying Authority may please preserve the duplicate copy of the certificate in his / her office provided by
the candidate.
PROFORMA A-II
Applicable for candidates residing in the State of West Bengal continuously at least for last ten (10) years as on
01.12.2023
To be issued by the Head of the Institution from which the candidate appeared/is due to appear in 10+2 or equivalent
examination.
Domicile Certificate: Type A-II
Certified that __________________________________________________ son/daughter of

_______________________________________________ has passed the 10+2 Examination in the year___________
/will appear in the final 10+2 Examination in 2024 from this institution.
It is also certified that the student is a resident / permanent resident of West Bengal at Village / House
no.___________________________________________________________ street
___________________________________________________ P.O. ______________________ P.S.
________________________________________________and has been living in the State of West Bengal continuously
/ uninterruptedly at least for the last ten years as on 01.12.2023.
Paste Passport size

in this box.
Note
Photograph is to be attested by the

Certifying Authority
Signature of Head of the Institution:
Designation with Official Seal:
Full name of Certifying Authority:
Address:
Phone No.: Mobile No.:
ID No.
Note: The Certifying Authority may please preserve the duplicate copy of the certificate in his / her office provided by the
candidate.
PROFORMA B
Applicable 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 the State.
To be issued by authorized persons other than Head of the Institution from which the candidate appeared/is due to
appear in 10+2 or equivalent examination.
Domicile Certificate: Type B
Certified that __________________________________________________ Father / Mother of

_________________________________(the applicant) is a permanent resident of West Bengal at village / house
no.___________________________________________________________ street
___________________________________________________ P.O. ______________________ P.S.
_______________________________________________________________________________________________
Paste Passport size

in this box.
Note
Paste passport size
Photograph is to be attested
photograph of Father /
Mother of applicant
by the Certifying Authority
Signature of Certifying Authority :
Designation with Official Seal :
Full name of Certifying Authority :
Address :
Phone No. : Mobile No. :
ID No.
Note : The Certifying Authority may please preserve the duplicate copy of the certificate in his / her office provided by
the candidate.

Domicile 2024 1

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PROFORMA FOR RESIDENTIAL/DOMICILE CERTIFICATE

Domicile Certificate: Type A-I

Certified that __________________________________________________ son/daughter of

Paste Passport size Note

Signature of Certifying Authority :

Designation with Official Seal :

Full name of Certifying Authority :

Phone No. : Mobile No. :

Domicile Certificate: Type A-II

Certified that __________________________________________________ son/daughter of

Paste Passport size

Photograph is to be attested by the

Signature of Head of the Institution:

Designation with Official Seal:

Full name of Certifying Authority:

Phone No.: Mobile No.:

Domicile Certificate: Type B

Certified that __________________________________________________ Father / Mother of

Paste Passport size

Signature of Certifying Authority :

Designation with Official Seal :

Full name of Certifying Authority :

Phone No. : Mobile No. :

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