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GovernmentofIndiaSchemeofPostMatricScholarshipOtherBackwardClasses
PARTA
Date:24/12/2015

RegistrationID:PMSOBCF6811623

ApplicantName(InBlock
Letters):

AMITKUMAR

Gender:

Male

Caste:

OBC

SubCaste:

Barai,Tamboli

Fathers/HusbandsName:

PAWANKUMAR

Nationality:

Indian

StateWherePermanentlySettled:

District:

Ambala

State:

Haryana

Area:

Rural

Block:

BLOCK

Village:

NEWTAGOREGARDEN

PhoneNo.:

7206531331

UIDNumber:

381224957630

FullAddress:

EmailAddress:

995,NEWTAGOREGARDEN
AMBALACANTT

zingamit61@gmail.com

NameandAddressoftheGuardianandRelationshipwithApplicant:

Name:

PAWANKUMAR

Relationship:

FATHER

Area:

Rural

Block:

BLOCK

Village:

NEWTAGOREGARDEN

Address:

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995,NEWTAGOREGARDEN
AMBALACANTT

InstituteDetail:

NameoftheInstitute:

GANDHIMEMORIALNATIONALCOLLEGEAMBALACANTT
YearofAdmission:

07/14/2015

Course/Trade:

B.com

Class/Semester:

12

PresentClassRollNo:

4910

BankDetail:

NameoftheBank:

INDIANOVERSEASBANK

LeadingBankAccountNo:

175101000012802

BankAddress:

GMNCOLLEGE

LeadingBankIFSCcode:

IOBA0001751

Widow:

No

Orphan:

No

HaveChildren:

No

Destitute:

No

OtherDetail:

BPlNO:

TuitionFeespaid:
Class/Sem

ActualTutionFeesPaid

12Sem

180

Item

Actualotherchargespaid

tuitionfee

17781

OtherChargesPaid:

Particularsofexaminationstakencommencingwiththematriculationorequivalentexamination(Pleaseattach
attestedcopiesofcertificates/marksheets.Anybreakineducationalcareershouldbementionedinremarks
columnindicatingalsohowhe/sheoccupiedhimshef/herselfinthatperiod)dulysupportedbyanaffidavitfrom
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thecompetentauthority.
NameofExamination

Yearinwhichtaken

Whetherpassedornotin
caseoflastexam.passed
indicatepercentageof
marksanddivision

SecodaryEducationXII

2015

66.8

University/Board

HARYANABOARDOFSCHOOL
EDUCATION

SignatureofApplicant

SignatureofHOD/Principal

i)I/WeherebydeclarethatI/Wehavereadtheregulationsoftheschemeandagreetoabidebythetermsandconditionsofthe
award.I/WEcertifythatthestatementsmadeintheapplicationsarecorrectandifanyofthemisfoundtobeincorrectbythe
authoritywhosedecisionwillbefinalandbindingonme/us.I/Weundertaketorefundtothesaidauthorityondemandtheentire
amountofscholarshiprecievedbyme/usoroverpaidtome/usfallingwhichthesaidauthoritymayrecovertheamountfrom
me/usthroughwhatevermeansitdeemproper.ThatIhavenotclaimedthebenefitfromanyotherschemes.
ii)I/Wefutherundertakethathis/herapplicationisbeingsubmittedfortheabovescholarshipforfirsttimeforthepresentclass.
Date:

(a)SignatureofApplicant

Place:

(b)Signature/left/righthandthumbimpression
oftheparents/guardians

PARTB
(TobefilledbytheHeadofInstitution)

Certifiedthat:

(i)InformationgivenbytheapplicantinPartAhasbeencheckedandfoundcorrect.
(ii)Thecourseinwhichtheapplicantisstudyinginthisinstituteisapostmatricone.
(iii)Thisinstituteisaffiliatedwith_________University/BoardandisrecognizedbythegovernmentofIndia/StateGovernment
__________Theapplicantisstudying__________courseinthisinstituteandtheminimumqualificationrequiredforadmissionto
thatcourseisapassinthe__________examination.
(iv)Certifiedthattheeligibilityofthestudenthavebeenrecheckdiscrepancyisnotified/discrepancynotifiedhasbeenreportedto
thedepartmentwithletterno.__________
(V)Certified(forscstudentsonly)thattheserialno.ofthisstudentis__________outofthetotaleligiblestudentstudyinginthis
institutionandhe/sheiswithinthe40%towhomthescholarshipistobegranted
(vi)Certifiedthattheapplicantnamedabovehasbeeregularinattendenceandhasabidedbythetermsandconditionofthe
schemeunderwhichthescholarshipisbeinggranted.
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(vii)certifiedthattheeligibilityofthestudenthasbeenrecheckedandnodiscrepancyisfound
(viii)His/herBiomatricAttendance(minimum70%):__________________outof______________workingdays=____________%
dated__________.
Incasetheapplicantleaves/migratestheinstitutionorotherwise,discontinuehis/herstudiesoracceptanyotherregular
scholarship/stipend,thefactswillbeimmediatelyreportedtotheconcernedauthorityrecommendingthatthepaymentof
scholarshiptotheapplicantbediscontinue.Incasetheattendenceofthestudentisfoundlessthan70%(BioMetricattendence)
thentheInstitutionshallrefundwithin15daysofclosureofexamination,theamountchargedonaccountofmaintenance
charges,feesetc.totheGovernmentbyDDintimationtoDepartment/DWO.
Place:

SignatureoftheHeadof

Institution:

Dated:
NameinCapitalLetters:

Designation:

Address:

PhoneNo:

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