Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0

Integrated Scholarship Application form- Post Matric Scholarships for year 2015-16
Applicant Code : 1569347 Scheme : Post Metric Scholarship for OBC
Application Number : 716719
Version No: 1 Verification Code: 5785 Lock Date: 17/10/2015 IPAddress : 182.70.170.90
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 sign in it.

1. Personal Details SAMAGRA ID : 142988612 Aadhaar No : 986513080919

Name : SAVITA YADAV As per SAMAGRA: Savita Yadav AS Per Board Marksheet : SAVITA YADAV
Gender : Female Religion : Hindu Special Category : No

Father's Name : AGAR AS Per Board Marksheet : AGAR SINGH YADAV

Mother's Name : RAMDEVI AS Per Board Marksheet : RAMDEVI YADAV
I O
Date of Birth : 02/07/1995 AS Per Board Marksheet : 02/07/1995

2.Category OBC AS Per Board Marksheet : OBC

Caste Certificate : No: 1652 Issued by :SDO KARERA On :07/07/2008 I O
3.Academic Details Admission Date : 16/08/2015 Enrollment No. : 0902EE131055 I O
University/Board Name : Rajiv Gandhi Technical University, Bhopal
Institute : Rustamji Institute of Technology, Tekanpur, Gwalior District: GWALIOR
Course : B E [Full Time]/Electrical Engineering/3Yr

IS-Hosteler: Non-Hosteler
4. 10th Board Details 10th Board Name: MP Board of Secondary Education, Year: 2010-11, Roll No.: 111616405

5. Last Year Exam Details : Exam Name: B E [Full Time]/Electrical Engineering/2Yr, Exam Date : 27/05/2015 I O
School./Institute :Rustamji Institute of Technology, Tekanpur, Gwalior Result : PASS
6. Total Annual Family Income : Rs.70000/-
Income Certificate issued by-TEHSILDAR On : 19/11/2014
7 Contact Details Mobile No : 8109471845 yadavsavita57[AT]gmail[DOT]com I O
Correspondance Address : VILLAGE KHOHA TEH KARERA, District :- SHIVPURI

Permanent Address : VILLAGE KHOHA TEH KARERA, District :- SHIVPURI

8. Bank Account No: 3212044301, IFS Code: CBIN0281320, CENTRAL BANK OF INDIA, OLD GWALIOR, GWALIOR I O
9. Previous Year Sanction Order Details Application ID : 467415 I O
Sanction Order No.: 1027626 Sanction Order Date: 08/07/2015 Sanction Amount: Rs.27810/-

]ȯ‘€fȲ”ȡ›€€ȧƒȪŸŽȡDeclaration from Student and his Parent

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(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

Delcaration from Institute Head & Institute Scholarship Nodal Officer

We, hereby, certify that student is enrolled in college in the course approved/recognized by concerned board/council/university. All details filled
by student in above application form have been verified with original documents & have been found to be correct / authentic. Applicant has
passed last exam. College has ORIGINAL COPY of his Transfer Certificate. Applicant is not enrolled in another institute. Applicant's attendance is
regular.
We have verified all details as per 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 it on portal and
to 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 legal and penal action against the institute.

(Signature of Institute Scholarship Nodal Officer) Date (Signature of Institute Director/Prinicpal)

Generated by Scholarship Portal as on 17/10/2015

Renewal Application Backward Classes & Minorities Welfare Dept.
Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2015-16
Applicant Code : 1569347 Scheme : Post Metric Scholarship for OBC
Application Number : 716719
Version No: 1 Verification Code: 5785 Lock Date: 17/10/2015 IPAddress : 182.70.170.90

Income Certificate Details

Previous Year MarkSheet

Fees Receipt/ Admission Slip

(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

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Generated by Scholarship Portal as on 17/10/2015