Government of West Bengal

Office of the PO cum DWO, NORTH 24 PARGANAS District

APPLICATION FOR POST MATRIC SCHOLARSHIP TO SC/ST / OBC STUDENTS (AY: 2021-2022)
NEW/RENEWAL Application Serial No. : WB010101605715

1. Full Name of Applicant Shri/Kumari : PUJA KARAN

2. Father's/Husband's Name : SHIBSHANKAR KARAN.
4. Date of
3. Gender : Female : 2006-04-21
Birth
5. Nationality : INDIAN
7. Telephone
6. Aadhar No : 259501129107 : 9831582488
No.

8. a) Caste : SC b) Sub-Caste : POUNDRA

c) Caste Certificate No : WB1103SC201706676 d) Dated : 2017-06-21
e) Issuing Authority,
: Basirhat
District
9. a)State to which applicant actually belongs : West Bengal
b) Permanent Address : JOYGOPALPUR
P.O. P.S. District PIN
JOYGOPALPUR SANDESHKHALI NORTH 24 PARGANAS 743446
c) Present Address : JOYGOPALPUR
P.O. P.S. District PIN
JOYGOPALPUR SANDESHKHALI NORTH 24 PARGANAS 743446
d) Whether in full time employment : No
10. Particulars regarding Father who supports in applicant’s studies
a) Name : SHIBSHANKAR KARAN
b) Occupation (if employed, give income certificate from the
: CULTIVATION
Employer)
c) Address : JOYGOPALPUR
11.Bank Details::
Bank Name Branch Savings A/C No. IFSC Code Address
PUNJAB NATIONAL HEAD OFFICE BMC
BANK BANGIYA GRAMIN HOUS E,NH
5585010009157 PUNB0RRBBGB
VIKASH BANK 34,CHUANPUR,P.O
.BERHAMPUR,DIST.MURS

12. a) Name of Institution (mentioning State / UT):SANDESHKHALI RADHARANI HIGH SCHOOL

Course Type:-
c)Actual date of joining the d)Tentative date of end of
d)Class of Study
class(Academic year 21-22 only) session(Academic year 21-22 only)
Group IV(XI) 2021-06-01 2022-05-31
 Government of West Bengal
Office of the PO cum DWO, NORTH 24 PARGANAS District
13.Annual Gross Income (parents / gurdians) from all sources : Rs. 36000/-
14.Whether applied for Merit/National Loan Scholarship or any other Stipend / Scholarship : No
15.Whether you in receipant of this scholarship in the previous year : YES, Amount Rs. 3000/- only

Hostel Details
Name & Address of Hostel Date of joining in current Session Charge payable

**For academic session 21-22 only**

(A certificate by Hostel Superintendent and duly countersigned by the Head of the Institution showing exact date of admission to
Hostel & charge payable to be submitted)
17.Identification Proof:Aadhaar Card No. XXXXXXXX9107
I agree to seed my aadhaar details with my bank account.
I undertake that all the statements given above are correct and I shall be liable to penal action if any statement made above is found
false/incorrect.

Place ------------------------------
Signature of the Applicant
Date ------------------------------

CERTIFICATE OF INSTITUTION

The statements made by the applicant in Sl. No. 12,14,15,16 are correct to the best of my knowledge. This Institute is affiliated to
the ______________________________________ University / Board & is recognized by the Government of India / State
Government of _________________________________. Minimum qualification for admission to the course is a pass in
____________________ Examination.
Certify that,the applicant has not applied for any other scholarship

SEAL
_____________________________________ Signature of Head of
Institution
Name (in Block Letter) :
Designation :
Address :
State :
Pin Code :
Affiliation/Registration No.
 Government of West Bengal
Office of the PO cum DWO, NORTH 24 PARGANAS District

INCOME & RESIDENTIAL CERTIFICATE

(Should be signed either by a Member of Parliament or Member of a State Legislature, or a Municipal Commissioner / Councillor /
Member of Zilla Parishad / Member,GTA / Savapati of Panchayat Samity or a Government Officer. The issuing authority is
requested to observe due caution as Scholarship is awarded on the basis of this very important Document.)
Certified that the information furnished at point nos. 1 to 11 and 13 overleaf are correct to the best of my knowledge.
Place ------------------------------

Date ------------------------------

SEAL Name (in Block

Letter) :
Designation :
Address :
State :
Pin Code :

DECLARATION OF INCOME

(To be given by the parents/ guardians when the candidate is not employed)
Certified that the gross annual income from all sources in respect of my family is Rs.____________ (Rupees
_______________________________Only) one / two / three of my sons is / are availing such scholarships. I make myself
responsible for the accuracy of the fact & figures furnished.I further undertake that in the event of the particulars given in the
declaration being found false, I shall refund the whole amount of the Scholarship paid to the said Scholarship holder
______________________________ and the Government's decision in this regard shall be final and binding on me.

Place ------------------------------
Signature in full
Date ------------------------------

1. Applicant is to submit the ***computer-generated filled-in application form (duly signed) to the Sandeshkhali - II Block
Development Office. .
2. Documents to be submitted along with computer generated application form:
A. 1(One) Copy recent stamp size coloured photograph of the applicant duly attested and pasted on the application.
B1. An attested copy of the caste certificate/Acknowledgement slip of the applicant(For prematric scholarship).
B2. An attested copy of the caste certificate of the applicant(For postmatric scholarship).
C. An attested copy of the marksheet/certificate of the last examination passed
D. Copy of the first page of bank passbook(where the account number and bank details is mentioned).
E. Copy of Identification Proof.
3. The required certificates on the body of the application form are to be provided by the concerned authorities /persons.
4. The application form has to be submitted by 30/09/2021.

Application Date:-2021-09-27