Application Form for PMS Academic Year :2019-20

Application ID :
Name of institute:
Personal Details
Applicant Name (आवेदक
का नाम)
Father's Name ((पिता का Affix Photo
नाम)
Mother's Name (माां का नाम)
Guardian's Name
(अपििावक का नाम)
Husband's Name
(िपत का नाम)

Permanent Address
(स्थाई िता)
Sub Category/Caste (उि
Category (वर्ग) श्रेणी / उि जापत)
DOB (DD/MM/YYYY)
Gender (प र्ां ) (जन्म की पतपथ (पिनाक
ां / महीना /
बर्ग))
Marital Status (वैवापहक Are you staying in hostel?
पस्थपत)
Religion ((धमग) Region (क्षेत्र)
Phone No With STD
Aadhar (आधार) Code (एसटीडी कोड के साथ फोन --
नांबर)
Mobile No (मोबाइ नांबर) E-Mail ID (ईमे आईडी)
Current Education Details (वर्तमान शिक्षा शववरण)
Place Of Current Study Course Nature
(वतगमान अध्ययन का स्थान) (िाठ्यक्रम की प्रकृ पत)
Course (िाठ्यक्रम) Specilization (पवशेर्ज्ञता)
Study Year/Semester Mode of Study (अध्ययन का
(अध्ययन वर्ग / सेमेस्टर) मोड)
College Type (कॉ ेज का
Seat Type (सीट प्रकार)
प्रकार)
Roll No. (रो नबां र)
Address (िता)
Board/University
(पवश्वपवद्या य / बोडग)
College/Institute Name
(कॉ ेज / सांस्थान का नाम)
Previous Qualification Details
Passing Month/Year
Course (िाठ्यक्रम) (उत्तीणग महीना / सा )
Marks Details (मार्कसग पववरण) Percentage (प्रपतशतता)
Roll No. (रो नांबर)
College/Institute Name
(कॉ ेज / सांस्थान का नाम)
Address (िता)
Board/University (बोडग /
पवश्वपवद्या य)

Applicant Bank Account and Fee details (आवेिक बैंक खाता और शल्ु क पववरण)

Total Fee Paid (कु शल्ु क का Applicant Account Number

िर्ु तान) (आवेिक खाता नांबर)
Applicant's Name (As Per
Bank Record) (आवेिक का नाम Bank Name (बैंक का नाम)
(बैंक ररकॉडग के अनसु ार))
IFSC Code (आईएफएससी कोड) Account Type (खाते का प्रकार)
Is Account Seeded with
Aadhar (र्कया बैंक खाता में आधार से
जड़ु ा है) ?
Branch Address (शाखा का िता)
Detailed Fee description

S.No. Fee Item Fee Amount (In Rs.)

1 BOARD/UNIVERSITY FEE
2 DEVELOPMENT FUND
3 EXAM FEE
4 STUDENT FUND
5 TUTION FEE

Gross Family Income From All Sources (For Financial Year .................)

Scholarship will be awarded to candidate with total family income less than 1.5 Lakh for OBC candidate ( नोट:
ओबीसी वर्त के आवेदक शिनकी कुल पररवार की आय 1.5लाख से कम है को छात्रवृशि प्रदान की िाएर्ी )
Gross Family Income From All Sources (आय) :

Income Certificate Issuing Authority((आय प्रमाण ित्र जारी

करने प्रापधकरण)
Income Certificate Number((आय प्रमाण ित्र नांबर)
Income Certificate Issue Date
(आय प्रमाण ित्र जारी पिनाांक)
Applied For Any Other Scholarship / Concessions
(पकसी िी अन्य छात्रवृपत्त / ररयायतों के प ए ार्ू)
Application ID of Other Applied
Scholarship/Concession(अन्य एप् ाइड छात्रवृपत्त / ररयायत के आवेिन
आईडी)
List of Documents Required

Sr. Document Name Document Status

.No.
1 Matriculation/Class 10 Certificate
2 Detailed Mark Certificate (DMC) of Last Qualification
3 Self-Attested Bank Passbook Copy
4 Self-Attested Copy of Aadhaar Card
5 Haryana Residence/Domicile Certificate
6 Income Certificate
7 Caste Certificate
8 Undertaking of Gap Year (If Applicable)
9 Paid Fee Receipt
10 Death Certificate of Father

Declaration
I/We hereby declare that I/We have read the regulations of the scheme and agree to abide by the terms
and conditions of the award. I/WE certify that the statements made in the applications are correct and if
any of them is found to be incorrect by the authority whose decision will be final and binding on me/us. I/We
undertake to refund to the said authority on demand the entire amount of scholarship received by me/us or
over paid to me/us falling which the said authority may recover the amount from me/us through whatever
means it deem proper. That I have not claimed the benefit from any other schemes. I/We futher undertake
that his/her application is being submitted for the above scholarship for first time for the present
class.

Applicant Signature

Head Of Institute Signature

Action Done on this form (for office use only)

Sr. No. Action Reason Comment Performed by Action date

verified/not verified if not verified