Government of Andhra Pradesh

Department of Backward Classes (EBC)

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

1. Application No: 2016 0862 2642

2. Application Date: 21-08-2016

4. Student Name : MADDINENI LEELA MADHAV

6. Father / Mother Name : MADDINENI VIJAYABHASKAR

3. Caste / Sub Caste: EBC(OTHERS) / Others (KAMMA).

5. Gender : Male

7. Address & Mobile No : DEGAPUDI, KALICHEDU ,Podlakur , Podalakur ,Nellore & 8886520542
8. SSC HT No : 1317108931

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

13. Income Certificate Details:

9. Pass Year -Pass Type : 2013-Regular

10. Date of Birth: 14-08-1997

12. Caste Certificate No : CGC011504998211

14.College Details : AUDISANKARA COLLEGE OF ENGINEERING AND TECHNOLOGY G2 , Gudur,Nellore , Private College ,JNT UNIVERSITY
ANANTHAPUR
15. Course Name /Course Year /Duration of Course : BTECH (CSE) / II Yr / 4Yrs

16. College Admission No / Admission Date(of this year): 15G21A0557 / 04-07-2016

17. Distance (in Kms.) :

20. Bank Name / IFSC Code: /

21. Bank A/c No :

18. Scholarship Type : Day Scholar

I.Declaration

19. DAH Name : -

40

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 21, 2016 11:29:19 AM