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Government of Karnataka

Department of Backward Classes Welfare

Student Application cum Verification Report for

Post-Matric/Food & Accomodation/Fee Concession Renewal 2016-17

1. Application No: 2016 0136 6552 2. Application Date: 12-09-2016 3. Caste Category / Caste: CAT-IIIB / VeerashaivaLingayath(Sl.No-3-(a))
4. Student Name : RANGANATH G 5. Gender : Male
6(a). Father Name : GURUSIDDAIAH S 6(b). Mother Name : MEENAKSHAMMA R

7. Address & Mobile No : EDENAHALLI ,Tiptur , Edenahalli ,TUMKUR & 9591846454

9. Pass Year: 2008-Karnataka
8. SSLC HT No : 20080668932 10. Date of Birth: 04-05-1993
SSLC Board
11.Family Annual Income (in Rs.): 12000 12. Ration Card : TIPU00127135
13.College Details(college Nature) : BANGALORE INSTITUTE OF MANAGEMENT STUDIES OPP RV COLLEGE MYSORE RD , Bangalore
South,Bangalore Urban , (Private College) ,Bangalore University, Bangalore
14. Course Name /Course Year /Duration of Course : MBA / II Yr / 2 Yrs
15. College Admission No / Admission Date(of this year): 332 / 08-08-2016 16. Distance (in Kms.) : 170
18. Scholarship Applied for: 1.Post-Matric/Food & Accomodation,2.Fee
17. Scholarship Type : Hosteller
Concession
19. Bank Name / IFSC Code: STATE BANK OF INDIA /SBIN0007500 20(a). Bank A/c No : 20140206615
(a).Income Caste Cert. No. : RD0039137053436 (b).Cat-1 Caste Cert. No.:

I.Declaration
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. .

Signature of the Student

Date :

II.Verification Report of College Principal

This is to certify that the information furnished above is verified with the records and found to be correct. He / She is a bonafide student of our
college studying in MBA / II Yr (Course & Course Year) during 2016-17 .

Signature of the Principal

Date :
(With College Seal)

III.Verification Report of Verification Officer/

I have verified the contents of scholarship Renewal application with reference to the college records and original certificates, physically
identified the student verified the following certificates

Caste : Yes No Income: Yes No SSLC: Yes No TC: Yes No Ration Card: Yes No
Other Details/Certificates if any:
I recommend for sanction of :
Post-Matric/Food & Accomodation/Fee Concession

I do not recommend the sanction of scholarship for the following reasons. (Please specify)

I have physically verified the SSLC Certificate in person

Date : Signature of the Verification Officer

September 12, 2016 11:26:19 PM

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