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Kum*. ............. . son / daughter of shri .of village / town in District ... in ............... ... state belongs to ........ ..community which is recognised as a backward class under :(1) Resolution No.12011/68/93-BCC dated 10th September 1993, published in the Gazette of India - Extraordinary - part 1, Section 1, No.186 dated 13t.

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