APP LICA TION FORM FOR SCH OLA RSH IP

(For Hon' ble Chi ef Minis ter Relie f Fund)

To .
•
The Hon'b le Chief lVIinister,
Gover nment of ,vest Benga l,
Naban na,
325, Sarat Chatte rjee Road ,
Howra h-711102

Personal Details
1. Name : <9A!31, A K rl flT UN
2. Guardi an's Name : A-NO WA-R MOL L lt
3. Date of Birth: () 1 / O 6 / 2- 0 0 5 4. Re Iigion : ----'~- 6
-=---'-_ft-_M
- --=- ----- ---
5. Gender : F l= MA L 6
Conta ct Detai ls
7. Perman entAdd ress: y lL L - t'< UNl) fl)' p.. o - It, , 9ft-6i'frP-\{t I P 11
S - ~ UL-Pl
8. Distric t: SOUT H ,f.l trR 6\ft Nit -5
2-Lj . 9 . PIN: 1- 4 833'L
10. Mobil eNo: f5 <S 5 3 2l 8 Sro 11 . Email :
-------------
Acad emic Detai ls

Name of Exam Board I University Year of Passin g Grade

I
I
% of Marks 1
I
I
,S J;CONO fl P- 't t;Jf3-~ T Bf; N ~fl L. BOM< O of::
~'ifl-M [Nft'T lO N 6 e=- c oNOfl RY
'2 02 l It I 66 °(,, I
J3-DVU) TID N I

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I

l
Curre nt Cours e Detaj ls
12.Cou rseNam e : ttl<nH f R 6 E3 CON0 fll2Y IS"><A MfNftf lON
13. Course Duratio n : __2-
_ 'f
-+--E_tl_R
_-5
_ _ _ __ 14. Season : 2. o 2.- I - 20 2-'L
15 . Name ofth e institut ion : ~ft-~tHitfl t< ttL--l kfl ~Oft-R-.St+~ '\J"lOYAMltNIJIR ( tt· SJ
16.Adc lrcss oftheln stitutio n: BA D)'ft P. l ft , l< UL-- PI , <S o UTt-t- 2. Lf p Qi'S
Bank Details
17. Accoun t Numbe r : 12 6 ·s- 0-1 02'2 7-7 3 5 18. IFSC Code: PO NBOt' L(, 5 '2.-o

19. Bank Name: PUNu ftG NflTIO N fl L-- 16hN K 20 . Branch Name : ___:.B::....:....
ft _61"_frR
_....:.lfl
:_:____ _ _ __
I hereby declare that all the above inform ation are correc t & true to the
be~t of my k nowledge and behalf.

Place : ~ ~ <fi't, R \ A

Date : J_'3 / 0 <t> / 2021.. Signatu re o f the Appl ican t

 SELF DECLARATIO N (1st TIME)

I am -
!f6~~, h.t Khoicm
~ -~-~ ~. . 1 - - - - - - - -
~ ~ 2 . . : : ::___i__
, Son of/Daughterr of Arwwttn.
I (Y1 o CJJ1,1,,_

_ _ _ _ _ _ _ _ _ _ . My current address is "1 r1- I< u "rld.e1.:t , P, o - Id • c;,, a;r...,;a. ,

___;_p_._s_-_ _K..:...;~:.____i::.._.- - - - - - - - - - ' Disttict S 0 1.). ~ l-Y PWl.a~ 5 and
PIN Code 7--Y 3 3 3 2- _"iC_,____
, do here by declare that I have been reading in Class _ Rt
2-oJ_ I- 2-- 2 : ; 3
_ _ _ _ _ _ _ _ _ _ _ _ . My cmTent academic session is 2019 20~0 at _ _ _ _ _ __

<Q, c,<r!: r,'; Cl Kcdi-b ftdan &__.., \[;dif'l=f(\d.i '° c s2

H•
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (School/College University Name & Address) and I
have not received any kind of Scholarships or Financial assistance for my current course from any
Govermnent Department or any Private Agencies during this year.

Signature of the Applicant

k,~1z--,
H~ ,.tJ J.tlw.11rd
8~r'~ ,t _., v~~W'llf (H .S 1
P() . :\ e q I'"~ . i< oi"' 7A o, .(S I

Counter Singed by the Head of the Institute with Seal

[www .WebExa111 .111J

 I RECOMENDATION FROM M.L.A.

To Whom It may Concern

I am - ~16o£
- 't- r<FzcdLFiJ
t o.- ~ r of lAnt,-9cll'r r.10 ~
- - - - - - - - - - - ,son of/daughter
_ _ _ _ _ _ _ _ _ _ _ _ , a permanent resident at - ~t,<
~u--'-n_ cL_~- + - - - - - - - - -
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , Post 11!enonda,.; ff
t;!,o a,r,{'o._

Police Station (s (.!'.f pi ,District 6 o u,ffi LY f "-n cr q,n CW

PIN

°c
~Lf'S 3 31--
7h !HJ> 4(?\J-<l arncl f>U r
in the State of West Bengal. My monthly family income is ,

Signature of the Applicant

Counter Singed by the M .L.A with Seal

Jogaranj an
M.L. A .l W .l:L J
133 Ku\p1
 4414~1 tfl'1~
·BABITA KHATUMN
d\ 11 "~ / DOB: 0 1/0 6/ 20 05
ll~ t / FEMALE

- - -- - -1!4-->tf-lfii-lllf-Ill--if-~~ - - - - - -- ·
'51Tl:t
92 42 28 93 15 52
"1fi4♦ t~
..,~.,
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:ii> '
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"Ii ,

AME BABITA KHATU N

K! D /~ OF ANOW ARMO LLA u~ .-~

,: 'f.' <

I~.
I ~
APPEARING FROM BA GARIA KALIKA ADARS HA VIDYAMANDIR ,iL~t
/HER COMBINATION OF SUBJECTS (IN SYMBOLS) I ~
BFL ESL
t"
SUBJE CT FULL MARK S ~

COMPULSORY SUBJECTS
INTERNAL
WRJTTEN FORMATIVE TOTAL
MARK S OBTAI NED
INTERNAL GRADE
l~r
WRJTTEN FORMATIVE TOTAL
FIRST LANGUA GE 90
EVALUATION
10
EVALUATION :4
100 63 ..

'IiJ,
10 73 A
f'

SECOND LANGUA GE 90 10 ~
100 53 09 62 A ...
-,;

MATHEMATICS 90 10 100 51 09 60 A ;
PHYSICAL SCIENCE 90 10 100 52 09 61 A
LIFE SCIENCE
I .•
90 10 100 59 10 69 A ii!l'r
HISTORY 90 10 100 58 10 68 A
GEOGRAPHY 90 10 100 64 09 73 A 1
OPTIONAL ELECTIVE SUBJECT 100
GRAND TOTAL --+ 466 ( Four Hundred Sixty Six) '

RESUL T ----+ p OVERA LL GRADE :

.
A
\
~k' 1
RESULT : I~
I
Grade Scale
90-100
Grade
AA
Performance Indicator
Outstanding
p
Comp.
For Successful Candidate
For Compartmental Candidate
i !~
I ,
I
80-89 A+ Excellent
X For Unsuccessful Candidate I
I

60-79 A Very Good Overall Grade is calculated dividing I!

Grand Total by 7_ _,{rrurnber of
\; i
45-59 B+ Good
Compulsory Subjects). 1i 1·
.

·1/: i~~
35-44 B Satisfactory
25-34 Candidate securing total marks with a
C Marginal fractional Percentage of 0.5 and above
D Disqualified is placed in the next higher grade.

~{~
Dt>puty Secretary (E~am.)
President
:-._..~~~~ .....I_ -,,./_ ..J

~ - f f j 1tlfJJ11nkNr t Index No. C2-250

- \ ~,ffilrilr
11
F~t\\~ ADMIT ~
': ~t':i 1!! ROLL I a114s2d No.,-- oo-s1--.j
.'.' ~ Registration No. I 7202-125916

BABITA KHATUN

:xi D I Wtxof ANOWAR MOLLA

to the Madhyamik Pariksha (Secondary Examination) 2021.
~ Her date of birth is FIRST day of JUNE (
Two Thousand FIVE.

SUBJECT CO M BIN A T I O N

FL-> BENGALI SL-> ENGLISH

j .------E,.xx~~~X~X~.XXXX>&~xfX~
1 BAGARIA KALIKA ADARSHA VIDYAMANDIR
~ {~
NB : i) This Admit Card should be carefully preserved. Deputy Secretary (Exam.)
~ 11) Alterauon made 10 the Admit Card w11hout the approval of the Board will disqualify the Candidate from s111ing at this or any subsequent Examinauon.
)i _ _ _ _ iii) The L~nguage5 m wh1c~ answers 1~ I.he !\on-Language subJ_l=5~5 can on~ be writtei: are ~cngal~~nglish, Hindi, Nepali, Od1a, Urdu and 01 Chiki.
 GOVERNMENT OF WEST BENGAL
OFFICE OF THE BLOCK DEVELOPMENT OFFICER
Kulpi, South 24 Parganas

Certificate No. : 0101032112029787

Dated : The 23rd day of August, 2021

Q I

To whom it may concern

This is to certify that Ms. Babita Khatun, daughter of Mr. Anowar Molla is a resident of Village : KUNDAY
, P.O . :
BERANDAR I BAGARIA , P. S. : KULPI in the District of South 24 Parganas, West Bengal.

The Ann ual income of her family is Rs . 36000 (Rupees Thirty Six Thousand Only) from all source as confirmed
and
ascertained by causing enquiry of BOO, Kulpi, Diamond Harbour.

Signatureil; ,ali
d
Digitally sig ESARSHI
MUkherjee
Date: 2021.08. 3 19:45:07 1ST

Block Development Officer

Kulpi
South 24 Parganas

• -
't.., a1 1therihcity of this document can be verified by accessing the URL: edistrlct.wb.gov.ln and then ciicklng - ·=
;,
, ,., 111,mrier 010 10321 12029 787. on the Venficalion of Digitally Signed Document' link an<' keyinQ n 1hr
Paae : 1
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Receipt No . .j 30
r-~~· BAGARIA Ke A. VIDYAMANDIR
';**'' P.O. - B. Bagaria~-
( _Higher Secondary )
P.S. - Kulpi, Dist. - 24 Pgs. (S)
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Dev. Fee/Other charges •......•.
Session fee .................. ~ ..... .
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~~ 7. Electnc . charges .................. .
i 8. Misee.•llaneous •••.•.••••••••••.

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Signature of Rec ; ·ng Clerk
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