GOVERNMENT OF ASSAM,

DIRECTORATE OF WELFARE OF PLAINS TRIBES & BACKWARD CLASSES,

ASSAM, RUKMINI NAGAR, GHY-6

Paste recent
Application form for “Special Incentive to ST (P) & OBC/MOBC Meritorious photograph
Students for the year 2020-21” with signature
overleaf

Sl.
All fields are to be provided Correctly in Block Letters only
No.
1 Name of Applicant :-

2 Name of Father/Mother/Guardian :-

3 Gender (Male/Female ) :-
Date of Birth :-
4
(Enclose age proof document)
Caste :-
5
(Enclose copy of Caste Certificate)
6 Mobile Number :-
Bank Details (Enclose copy of Bank Pass Book)
Name of Bank & Branch :-

7 Bank Account Number :-

IFS Code :-
** Students should have their individual bank account.
Address (Permanent & Present)
Village/ City :-
PO :-
8 PIN :-
District :-
State :-
(Enclose address proof document)
Name of Institute where the students :-
9
passed from
Qualification & Year of Passing
10 (Enclose copy of last exam pass :-
certificate/ mark sheet)
Percentage of Marks :-
11
(Copy to be enclosed)
12 Aadhaar Number (if available) :-
Declaration:
I declare that the above information’s are true and correct to the best of my knowledge
and belief.
13
Place :-
Dated:- (Signature of applicant)

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