Annexure-1 (Revised 2019-20) SPECIMEN COPY OF EX-SERVICEMAN / EX-COAST GUARD CERTIFICATE (in lieu of Discharge Book) (USE BLUE INK PEN ONLY) Type of Service (Army S 4. | Navy [Air Force / Coast | Al FORCE | 2. | Service Number FE0619-B Guard) Rank SERGEANT | a, | Name of ESM [RANDH/R SINGH THENTUA | 2_/031199) | @ | Date of Discharge! | 3! _jo3 ; 2014 Retirement (daimmiyyyy) jekfeal eats Duration Length Date of Enrolment PPO Number [er 1 4- 8. | of Service 23 _Years & Months Reason for Discharge? [GN FULFILIN = CONDITION SF ENESLIGENT ON | Retirement RE EXPIRY ESM/Widow Identity |U/P-as[ooQ4es | 44 | ESM / Widow Identity Gard Cua 986 | Card Number & Date 09919 Le | the student applying PM Scholarship (PMSS) --__| 72 | Particulars of ALL Dependent Children including Sei ‘Neme ‘Bom During | Gender PMSS Earlier Me) Service or After Availed / Not Retirement. Availed (a) YATR? eS ce & [Naar 29-3.1999) MOT AVAILED ow FA ae ST fins7aenie|og.2-200]| NoTAVAILED @ = a = = ~ a Note : - Scan and upload an affidavit self cerificate if, the ward Is born after retirement [release of Ex-serviceman, +43,| Date of Death of 4a] Cause of Death = | ESM (if applicable) | —(ddimmiyyyy) '| (if applicable) 5 a were attributab! il = 715 Whemer ine deat / iaaomy attributable to Military / Coast You) NS (rik out) 16.| Category of ESM__ 5 (Fillup category 1 to 6 as per prionty given below after assessing the documents of Ex Serviceman) :- Priority for Grant of Scholarship. ‘Order of preference for selection of candidates will be as under: Category 1 Wards / Widows of SM / Ex Coast Guard personnel killed in action Category 2 Wards / Widows: ct ESM | Ex Coast Guard personnel disabled In action and boarded out of service with disability attributable to Military / Coast Guard service. Category 3. Wards / Widows of ESM / Ex Coast Guard personnel who died while in service for causes attributable to Military ! Coast Guard Service. Category4 Wards / Widows of ESM / Ex Coast Guard personnel disabled in service with disability attributable to Military / Coast Guard Service. Category § Wards / Widows of ESM / Ex Coast Guard personnel in receipt of Gallantry Awards, 6 Wards / Widows of ESM / Ex Coast Guard perscnnel (PBOR Only). 1. Check particulars/dependability of student in discharge book of ESM, proof for catagory, 10° class certificate” mark sheet for DOB, MEQ cettificate, Aadhaar Card, bank account pass book (SBUPNE), Annexure 2 & 3 and affidavits certificate if bom after retirement bafare signing of this certificate to avoid subsequant visits of ESM/student. 2. For’ signature will not be accepted. 3. Itis certified that the above information is checked from the Discharge Book of Ex-Servicemien / Ex-Coast Guard personal, found correct and ESM name has been registered with this 2SB/DGCG. (Signatu (Rubber Qtarep 8 Affixed)