8/31/2017 NATIONAL SCHOLARSHIP PORTAL 2.0 [APPLICATION ID. JkAz0TTI 8005140093 [REGISTRATION DAT 31082017 [APPLIED FOR SCHEME, \staTe OF DOMICILE SCHOLARSHIP [POST MATRIC SCHOLARSHIP (PMS) FOR ST STUDENTS-KARNATAKA, |cATEGORY. : DATE OF BIRTH [50 5 NAME OF STUDENT — JSUGANDHT MDDIIMIYYY) 30/06/2000 [GENDER RELIGION AINDU [COMMUNITYICATE [FATHERS NAME GOVINDA NAIK ANNUAL FAMILY MOTHERS NAME ome 11000 [KADHAR NUMBER MOBILE NUMBER _[s742771184 DAY ScHOLARMosTELER|VOSTTLER |PRESENT INSTITUTE [VARASIDDHI VINAYAKA PRE UNIVERSITY COLLE GF ENT OI [CLASS START DATE osrar2017 q MODE OF STUDY REGULARIFULL TIME KARNATAKA SECOND DARY EDUCATION EXAMINATION BORAD, SANGALORE FrREvrors on IREVIOUS FASSNG |p. cLasSiCOURSE NAME year Peavious cia los er CLASSROTEooreosooo2 . NOTHICUASS BOARD” RARNATARA SECONDARY EDUCATION Ps aM EXAMINATION BORAD, BANGALORE fz crass ROLL No ra Lb TAIN CLASS nOARD Nae [COMPETITIVE EXAM TXAM CONDUCTED |QUALIFIED BY [coupe ERAN IconrETrnVE ERAN Rouse ean IRDNISSION FEE ——— 700 hromiox rex —— [aon fscree Fe IS ORPHAN Ro RO ym OF DAMEN PERCENTAGE OF byrcorpiamury PERcENTAG : ; ; PARENTS - hrarran stars [ow Mannie PARENTS ores ee 5 BANK ACCOUNT = lrsc cone rpo0028 IpANKCAc razs01 000 rare EARNATARA TST oor BLOCK FcaNDAPURA INoparse frarconu nous? Ion coon _— JSELKODU MUDUR GRAMA| SIGNATURE OF CANDIDATE, SIGNATURE OF HEAD OF SCHOOL/INSTITUTE/COLLEGE WITH STAMP.