Annexure-1 (Revised 2022-23)

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
10. 11. Name of Identity Card Issuing ZSB
Card Number & Date
12. Particulars of ALL Dependent Children including the student applying PM Scholarship (PMSS) :-
Ser Name Date of Gender Married / Born During PMSS Earlier
No Birth Unmarried Service or After 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/CG
1. Check particulars/dependency of student in discharge book of ESM, proof for category, 10th class certificate/ mark
sheet for DOB, MEQ certificate, Aadhaar Card, bank account pass book (preferably 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)