Government of Andhra Pradesh

Department of Backward Classes

Student copy of Application for
Post-Matric Scholarship Renewal 2016-17

1. Application No: 2016 0872 2633

4. Student Name : KOSURU SAI HEMANTH

2. Application Date: 02-08-2016

6. Father / Mother Name : KOSURU ADI SESHAIAH

7. Address & Mobile No : PAATIMIITA CHENNUR ,Gudur , Chennuru - I ,Nellore & 8886231429
8. SSC HT No : 1517130231

11.Family Annual Income (in Rs.): 40000

9. Pass Year -Pass Type : 2015-Regular

13. Income Certificate Details:

3. Caste / Sub Caste: BC-B / Gamalla(Sl.No.-4)

5. Gender : Male

10. Date of Birth: 17-02-2000

12. Caste Certificate No : CGC011505220263

14.College Details : AUDI SANKARA COLLEGE OF ENGG ANDTECG(2 SHIFT POLYTECHNIC) , Gudur,Nellore , Private College ,STATE BOARD
OF TECHNICAL EDUCATION AND TRAINING
15. Course Name /Course Year /Duration of Course : DIP (EEE) / II Yr / 3Yrs

15

16. College Admission No / Admission Date(of this year): 15280-EE-046 / 04-07-2016

17. Distance (in Kms.) :

20. Bank Name / IFSC Code: SBIN-CHENNUR /SBIN0012687

21. Bank A/c No : 35278640025

18. Scholarship Type : Day Scholar

I.Declaration

19. DAH Name : -

I hereby certify that that above information furnished is true. I have not availed any other scholarship for this purpose from any other sources. I
shall abide by the terms and conditions of the sanction of the scholarship. If any discrepancies are found later, I hereby abide for refund of the
scholarship amounts claimedand also am liable for action by the Department. .
Date :

Signature of the Student

August 2, 2016 04:31:47 PM