Selection Serial Number......................

PROFORMA FOR RENEWAL OF SCHOLARSHIP UNDER PRIME MINISTERS SCHOLARSHIP SCHEME (To be send only if selected for scholarship)

1.

Name of the applicant (Ward/widow):

2.

Put a tick mark ()

Male

Female

1. Selection serial No. given by KSB:

4.

Particular of ESM / Ex-Coast Guard:

Name of ESM / Ex-Coast Guard Rank Service Number 5. Present address (where you want your letter is to be sent) (To be filled up only in case of change from previous address or write N / A)

House No.

Street No. & Name

Tehsil & Post

Distt State

Pin Code

6. Details of Bank account of SBI or PNB for Electronic Clearing Services ((PLEASE
ATTACH A PHOTOCOPY OF PASS BOOK, CROSSED BLANK CHEQUE SHOWING YOUR ACCOUNT NUMBER TO BE FORWARDED, EVEN IT IS SUBMITTED EARLIER).

Name of account holder

Bank Name

LEAVE BLANK SPACE BETWEEN WORDS Branch Name

Branch Address

State

Bank Tel. No.

Branch

Code

MICR (9 digit) No.

(PLEASE ATTACH A PHOTOCOPY OF CHEQUE & PASS BOOK)

Account No. REPEAT

Account No.

It is certify that the information submitted by my child / self is correct.

Place:________________________________

Date: ______________________

Full Name & Signature of the ward / widow

Please Fill Properly Your Full Year (Both Semesters) Marks

1. It is certified that Ms. / Mr._____________________ is a student of

__________________________________ College. He / she is studying in I / II / III / IV / V year of the two / three / four / five years _______________ course. He / she had joined this college in the academic year 20___ - ___ and the course will be completed in the month of ____________ 20___ - ___. 2. This is also certified that Ms. / Mr. ___________________________

__________ has successfully completed his / her 1st / 2nd / 3rd / 4th year and scored Year 1st Year (1st & 2nd sem) 2nd Year (3rd & 4th sem) 3rd Year (5th & 6th sem) 4th Year (7th & 8th sem) 3. Marks Obtained ____________ ____________ ____________ ____________ Out of _____ _____ _____ _____ Percentage ________ ________ ________ ________

He / she is continuing the course in 2nd / 3rd / 4th year.

Signature of Principal / Dean / Registrar

Office Seal:

Date: ________________ Place: _______________