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Backward Classes & Minorities Welfare Dept.

Renewal Application

Madhya PradeshScholarship Portal 2.0


Integrated Scholarship Application form- Post Matric Scholarships for year

2014-15

Applicant Code : 1605471


Application Number : 546925

Scheme : Post Metric Scholarship for OBC

Lock Date: 25/12/2014 IPAddress : 182.70.219.212


Version No: 1
Verification Code: 4342
Instructions for colleges & offices: Please check all information in each section and place a tick mark in on the box. Institute
will use the first Box with I sign and Sanctioning Office will use second box with O sigh in it.
Previous Year Scholarship Details

1. Personal Details

SAMAGRA ID : 121663077

Name : SATEESH KUSHWAHA

Gender :

No Scholarship sanctioned last year

Aadhaar No : 787552469990

As per SAMAGRA: Satish Kushwaha

Male

Religion :

As Per Board Marksheet : SATEESH KUSHWAHA

Special Category :

Hindu

Father's Name : TEJBALI

As Per Board Marksheet : TEJBALI KUSHWAHA

Mother's Name : CHANDRAVATI

As Per Board Marksheet : CHANDRA VATI KUSHWAHA

Date of Birth :

15/06/1989

2.Category OBC

As Per Board Marksheet : OBC

Admission Date :

3.Academic Details

Course :

As Per Board Marksheet : 15/06/1989

Caste Certificate : No: 34324 Issued by :Tehsil Office Huzur Rewa On :04/08/2003

Institute :

No

11/09/2014

Enrollment No. :

132021630059

Govt Law College, Rewa District: REWA


LL. B./LL. B./2Yr

Hostel Admission Date: Non-Hosteler


10th Board Name: MP Board of Secondary Education, Year: 2004-05, Roll No.: 153219512

4. 10th Board Details

5. Last Year Exam Details :

Exam Name: LLB, Exam Date : 10/06/2014

School./Institute :GOVT LAW COLLEGE REWA

6. Total Annual Family Income :

Result : PASS

Rs.30000/-

Income Certificate issued by-NAYAB TEHSILDAAR HUZUR On : 30/09/2014


7 Contact Details

Mobile No :

Correspondance Address :

7898454126

satish121663077[AT]gmail[DOT]com

VILLAGE POST MANKAHARI TEHSIL HUZUR, District :- REWA

Permanent Address :
VILLAGE POST MANKAHARI TEHSIL HUZUR, District :- REWA
8. Bank Account No: 31860658685, IFS Code: SBIN0003179, STATE BANK OF INDIA, GEC REWA, REWA

]fDeclaration from Student and his Parent


We, SATEESH KUSHWAHA S/o TEJBALI and TEJBALI hereby declare that Board Roll No, Samagra ID, caste certificate and income certificate,
bank account details and all other information given in the application form is complete and correct. We have not submitted any other application for
scholarship for current academic year in any other institution in India. We also undertake that, if any information given above is found to be false at
any stage, entire amount of scholarship will be recovered and competent authority will be free to initiate legal penal action against us.

SATEESH KUSHWAHA S/o TEJBALI kTEJBALI `f]_CB[


[]\`\[f@][^
ff]@\`_]f
f[@

(Signature of Parent /  Date

(Signature of Student / ]

Delcaration from Institute Head & Institute Scholarship Nodal Officer


We, hereby, certify that the student is enrolled in the approved course of Govt MP. All the details filled by the student in the above application
form have been verified with the original documents and have been found to be correct and authentic. He has passed last exam and is eligible for
sanction of scholarship. College has ORIGINAL COPY of his School Leaving Certificate. His attendance is regular, as per the instructions of
Government
We have verified all details as per te scheme guidlelines & instructions and recommend him for sanction of scholarship as per the rules. We also
undertake that, if the above student does not attend the classes regularly or discontinues the course, We will immediately report the matter to the
concerned district office so that his scholarship can be put on hold. In case any information of found to be incorrect, Government will be free to
initiate action against the institute.
(Signature of Institute Scholarship Nodal Officer)

Date

(Signature of Institute Director/Prinicpal)

Generated by Scholarship Portal as on 12/25/2014

Renewal Application

Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0


Integrated Scholarship Application form- Post Matric Scholarships for year

2014-15

Applicant Code : 1605471


Application Number : 546925
Version No: 1

Scheme : Post Metric Scholarship for OBC

Verification Code: 4342

Lock Date:

25/12/2014

IPAddress : 182.70.219.212

Your 10th Board Details 10th Board Name: MP


Board of Secondary Education, Year: 2004-05, Roll
No.: 153219512

Caste Certificate Details No: 34324 Issued by


:Tehsil Office Huzur Rewa On :04/08/2003

ALERT: Details of Applications already registered by using same Samagra ID :


Nil
ALERT: Details of Applications already registered by using same 10th Board Roll No :
Nil

(Signature of Parent /  Date

(Signature of Student / ]


Generated by Scholarship Portal as on 12/25/2014

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