soe eee Application to the Deputy Commissioner we SUHRID | {zing financial assistance for EDUCATION” Benefit under MLA Area Development Fund (SUHRID), Govt. of Assam. & LAC: (Fital fetis n BLOCK LETTERS) (Ftie markedos® ore 4.Name of Applicant” 2. Date of Birth:* 3.Gender* [Male DiFemale Clother 4a) Guardian's Name" 4(0), Guardian's Occupation™. 4c) Relationship:*(rick One) Father / Mother / Spouse / Uncle / Aunt / Brother / Sister / Grandfather / Grandmother / Others. (with appicant) 5. ADDRESS IN FULL: (See Overieaf for Instructions on Address fies) (a) District :*_ (b) Circte* (FOR URBAN AREA) (FOR RURAL AREA) Photo” (©) Municipality (MC/MB/TC)* (@) Block* GPIB (d) Ward \(g) Village (r)PostOffice, (I) Police Station \@) Locality:* (k) PIN Code™ 6.Caste* General OST(P) OST(H) CSc osc Omosc 7.Community: [Minority ()Tea Tribes 8.Religion* Hindu (Muslim CJChristian )Sikh COBuddhist Clvain Cothers — 9.Mobile:*| 40,BANK AND PAN DETAILS: (@) Bank Name:* (6) Branch”, (©) Branch IFSC :* (@) Account No.* (e) Account Holder's Name* () PAN No. 44, EDUCATION DETAILS: (@) Qualification of the Beneficiary* Details of Course for which benefit is sought f (&) Course Type* SLC CIHSSLC }§=QuG CPG LiVocational CiDipioma (c) Course Names (4) Name & Address of the Institution (e) Date of Admission into the Course:* 12, Whether any Family Member of the Beneficiary is a Government Employee* LIYES LINO 13. Whether any Govt. Aid is received earlier under any Head? (If Yes, please give details)* []YES [INO 14.(a) ID Proof Type. (b) ID Number*® (©) Name on ID * 16. Enrolled in Aadhaar? LIYES LINO (if YES, provide Aadhaar Number: ) 16. Signature of the Head of the Institution with Seal” 17. Recommendation of the MLA concerned with Seal* Amount Recommended: & Date: Seal & Signature of Head | | Date: Seal & Signature of MLA, Declaration: (1) | hereby declare that the information provided above is true to the best of my knowledge. (2) Ihereby allow the usage of my Aadhaar Data for official purposes. Date* - Place*- Signature of applicant* "HRESTITanSdov assam GOV MBCPOTOSBUNTESEPOTS “eRopanio7 SURRIG EDUCATION ¥7