S.No. of Application {fix a passport size photo at right of application}
GOVERNMENT OF ANDHRA PRADESH DEPARTMENT OF HIGHER EDUCATION APPLICATION FOR POST MATRIC SCHOLARSHIP FOR STUDENTS OF ECONOMICALLY BACKWARD CLASSES.
College Name & Place Govt Aided Pvt Mandal District
College Admission Number Date of Admission
Academic year Course Year 1st/2nd/3rd/Final
1. Full Name (in Block letters) (To be filled by the Candidate) (Surname Name) 2. Father’s Name 3. a) Guardian’s Name (if father & mother are not alive) b) Spouse’s Name (for married Candidates) 4. a) Present Postal Address
b) Permanent Address
5. a) Whether passed-SSC/CBSE/ICSE/Matric/Other State Board
b) Regd/Hall ticket number of SSC or Equivalent Exam passed with Month and year of Passing 6. Date of Birth (as shown in Xth class memo) 7. Sex ( Male/Female) 8. Nationality & Religion 9. Community 10. Year of passing in the previous Course. 11. Details of Present Course of Study a) Name of the Course
b) Duration (No. Years)
c) From______(month) To _________ (month)
12. Place of Present Residence
13. Distance between College and Residence: KMs 14. Family Annual Income : Rs.
15. Family Ration Card No./Electoral roll Number of Parent 16. Date of Admission in College attached Hostel(if so) 17. Student`s Bank A/C No. Name of the Bank & Branch 18. Year wise study particulars SSC Onwards (Specify if there is any gap in studies) S.No. Year of Study Course of study Result % of Marks Name and Address of School/ College
It is to declare that the above information is true and correct. If it is proved to be false we will be held responsible and action can be initiated against us.
Signature of the Parent/Guardian/Husband Signature of the Candidate.
( To be filled by the Educational Institution)
The contents of the application have been verified with reference to the original documents submitted by the candidate to the institution and the photocopies of the same are enclosed herewith.
Enclosures:
1. Copy of Community Certificate 2. Copy of the Income Certificate 3. Copy of the SSC Marks memo. 4. Copy of the Certificate/Marks memo of the course last studied. 5. Copy of the Transfer Certificate of previous Course. 6. Copy of the Ration Card or Electoral Roll No. of the parent.
7. Bonafide Certificate issued by the Principal.
Tel No. Signature & Name of Place: the Principal of the Date: Educational Institution Seal:
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APPLICATION FORM
S.No. of Application {fix a passport size photo at right of application}
GOVERNMENT OF ANDHRA PRADESH
DEPARTMENT OF HIGHER EDUCATION
APPLICATION FOR POST MATRIC SCHOLARSHIP FOR STUDENTS OF ECONOMICALLY BACKWARD CLASSES.
College Name & Place Govt Aided Pvt
Mandal District
College Admission Number Date of Admission
Academic year
Course Year 1st/2nd/3rd/Final
1. Full Name
(in Block letters)
(To be filled by the Candidate)
(Surname Name)
2. Father’s Name
3. a) Guardian’s Name
(if father & mother are not alive)
b) Spouse’s Name
(for married Candidates)
4. a) Present Postal Address
b) Permanent Address
5. a) Whether passed-SSC/CBSE/ICSE/Matric/Other State Board
b) Regd/Hall ticket number of SSC or Equivalent Exam passed with Month and year of Passing
6. Date of Birth (as shown in Xth
class memo)
7. Sex ( Male/Female)
8. Nationality & Religion
9. Community
10. Year of passing in the previous Course.
11. Details of Present Course of Study
a) Name of the Course
b) Duration (No. Years)
c) From______(month) To _________ (month)
12. Place of Present Residence
13. Distance between College and Residence: KMs
14. Family Annual Income : Rs.
15. Family Ration Card No./Electoral roll Number of Parent
16. Date of Admission in College attached Hostel(if so)
17. Student`s Bank A/C No.
Name of the Bank & Branch
18. Year wise study particulars SSC Onwards (Specify if there is any gap in studies)
S.No. Year of Study Course of study Result % of Marks Name and Address of School/
College
It is to declare that the above information is true and correct. If it is proved to be false we will be held responsible and action can be initiated against us.
Signature of the
Parent/Guardian/Husband Signature of the Candidate.
( To be filled by the Educational Institution)
The contents of the application have been verified with reference to the original documents submitted by the candidate to the institution and the photocopies of the same are enclosed herewith.
Enclosures:
1. Copy of Community Certificate
2. Copy of the Income Certificate
3. Copy of the SSC Marks memo.
4. Copy of the Certificate/Marks memo of the course last studied.
5. Copy of the Transfer Certificate of previous Course.
6. Copy of the Ration Card or Electoral Roll No. of the parent.
7. Bonafide Certificate issued by the Principal.
Tel No. Signature & Name of
Place: the Principal of the
Date: Educational Institution
Seal:
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