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 /

1. Navy / Air Force / Coast 2. Service Number
Guard)
3. Rank 4. Name of ESM

___/___/_____ Date of Discharge / _____/____/_________

5. Date of Enrolment 6.
(dd/mm/yyyy) Retirement (dd/mm/yyyy)
Duration / Length
7. PPO Number 8. _____Years &_____Months
of Service
Reason for Discharge /
9.
Retirement
ESM / Widow Identity ESM / Widow Identity Card issued
10. 11.
Card Number & Date by whom (Write Name of ZSB)
12. Particulars of ALL Dependent Children including the student applying PM Scholarship (PMSS) :-
Ser Name Born During Gender Married / Date of PMSS Earlier
No Service or After Unmarried Birth Availed / Not
Retirement Availed

(a)

(b)

(c)

Note : - Scan and upload an affidavit / self certificate if, the ward is born after retirement / release of
Ex-serviceman.
Date of Death of ____/____/_______ Cause of Death
13. 14.
ESM (if applicable) (dd/mm/yyyy) (if applicable)
15. Whether the death / disability were attributable to Military / Coast
Yes / No (Tick out)
Guard Service ?
16. Category of ESM ________________ (Fill up category 1 to 6 as per priority 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 ESM / Ex Coast Guard personnel killed in action.
Category 2 Wards / Widows of 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.
Category 4 Wards / Widows of ESM / Ex Coast Guard personnel disabled in service with disability
attributable to Military / Coast Guard Service.
Category 5 Wards / Widows of ESM / Ex Coast Guard personnel in receipt of Gallantry Awards.
Category 6 Wards / Widows of ESM / Ex Coast Guard personnel (PBOR Only).
Instructions for ZSB/DGCG
th
1. Check particulars/dependability of student in discharge book of ESM, proof for category, 10 class certificate/ mark
sheet for DOB, MEQ certificate, Aadhaar Card, bank account pass book (SBI/PNB), Annexure 2 & 3 and affidavit/self
certificate if born after retirement before signing of this certificate to avoid subsequent visits of ESM/student.
2. `For’ signature will not be accepted.
3. It is certified that the above information is checked from the Discharge Book of Ex-Servicemen / Ex-Coast Guard
personal, found correct and ESM name has been registered with this ZSB/DGCG.

Date: _________ Round Stamp of

ZSB Office (Signature of Secy ZSB/ DGCG)
Place: ___________
(Rubber Stamp of Signing Officer to be Affixed)