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    This document is an application for a post-matric scholarship submitted by Sujit Roy, a male OBC student born in 2000. He is applying for the scholarship to fund his diploma engineering studies at Malda Polytechnic in West Bengal. Details provided include his family's income of Rs. 60,000 per year and bank account information. The institution certificate confirms his enrollment in the third year of a diploma engineering program. He was a recipient of the scholarship last year for Rs. 2,800. The application requires additional documents and certificates to be submitted by November 30th, 2021.

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    This document is an application for a post-matric scholarship submitted by Sujit Roy, a male OBC student born in 2000. He is applying for the scholarship to fund his diploma engineering studies at Malda Polytechnic in West Bengal. Details provided include his family's income of Rs. 60,000 per year and bank account information. The institution certificate confirms his enrollment in the third year of a diploma engineering program. He was a recipient of the scholarship last year for Rs. 2,800. The application requires additional documents and certificates to be submitted by November 30th, 2021.

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    This document is an application for a post-matric scholarship submitted by Sujit Roy, a male OBC student born in 2000. He is applying for the scholarship to fund his diploma engineering studies at Malda Polytechnic in West Bengal. Details provided include his family's income of Rs. 60,000 per year and bank account information. The institution certificate confirms his enrollment in the third year of a diploma engineering program. He was a recipient of the scholarship last year for Rs. 2,800. The application requires additional documents and certificates to be submitted by November 30th, 2021.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    104 views3 pages

    PDF View

    Uploaded by

    Pà Páï
    This document is an application for a post-matric scholarship submitted by Sujit Roy, a male OBC student born in 2000. He is applying for the scholarship to fund his diploma engineering studies at Malda Polytechnic in West Bengal. Details provided include his family's income of Rs. 60,000 per year and bank account information. The institution certificate confirms his enrollment in the third year of a diploma engineering program. He was a recipient of the scholarship last year for Rs. 2,800. The application requires additional documents and certificates to be submitted by November 30th, 2021.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    Government of West Bengal

    Office of the PO cum DWO, MALDAH District

    APPLICATION FOR POST MATRIC SCHOLARSHIP TO SC/ST / OBC STUDENTS (AY: 2021-2022)
    NEW/RENEWAL Application Serial No. : WB040217385908

    1. Full Name of Applicant Shri/Kumari : SUJIT ROY


    2. Father's/Husband's Name : BADAL ROY.
    4. Date of
    3. Gender : Male : 2000-04-04
    Birth
    5. Nationality : INDIAN
    7. Telephone
    6. Aadhar No : 359072158156 : 8116144942
    No.

    8. a) Caste : OBC B b) Sub-Caste : BAISHYA KAPALI


    c) Caste Certificate No : WB0602OBC201600208 d) Dated : 2016-01-06
    e) Issuing Authority,
    : Sadar(Malda)
    District
    9. a)State to which applicant actually belongs : West Bengal
    b) Permanent Address : VILL-KHARIKADIGHI,P.O-MOYNA,P.S-GAZOLE,DIST-MALDA,PIN-732124
    P.O. P.S. District PIN
    MOYNA GAZOLE MALDAH 732124
    c) Present Address : VILL-KHARIKADIGHI,P.O-MOYNA,P.S-GAZOLE,DIST-MALDA,PIN-732124
    P.O. P.S. District PIN
    MOYNA GAZOLE MALDAH 732124
    d) Whether in full time employment : No
    10. Particulars regarding Father who supports in applicant’s studies
    a) Name : BADAL ROY
    b) Occupation (if employed, give income certificate from the
    : FARMER
    Employer)
    c) Address : KHARIKADIGHI,MOYNA,GAZOLE,MALDA,732124
    11.Bank Details::
    Bank Name Branch Savings A/C No. IFSC Code Address
    STATE BANK OF
    INDIA DIST MALDA.W B
    GAZOLE 35051554880 SBIN0002058
    73212 4

    12. a) Name of Institution (mentioning State / UT):MALDA POLYTECHNIC, MALDA


    Course Type:-
    c)Actual date of joining the d)Tentative date of end of
    d)Class of Study
    class(Academic year 21-22 only) session(Academic year 21-22 only)
    Group IV(Diploma Engineering 3rd year) 2022-02-04 2022-12-31
    Government of West Bengal
    Office of the PO cum DWO, MALDAH District
    13.Annual Gross Income (parents / gurdians) from all sources : Rs. 60000/-
    14.Whether applied for Merit/National Loan Scholarship or any other Stipend / Scholarship : No
    15.Whether you in receipant of this scholarship in the previous year : YES, Amount Rs. 2800/- only

    Hostel Details
    Name & Address of Hostel Date of joining in current Session Charge payable

    **For academic session 21-22 only**

    (A certificate by Hostel Superintendent and duly countersigned by the Head of the Institution showing exact date of admission to
    Hostel & charge payable to be submitted)
    17.Identification Proof:Aadhaar Card No. XXXXXXXX8156
    I agree to seed my aadhaar details with my bank account.
    I undertake that all the statements given above are correct and I shall be liable to penal action if any statement made above is found
    false/incorrect.

    Place ------------------------------
    Signature of the Applicant
    Date ------------------------------

    CERTIFICATE OF INSTITUTION

    The statements made by the applicant in Sl. No. 12,14,15,16 are correct to the best of my knowledge. This Institute is affiliated to
    the ______________________________________ University / Board & is recognized by the Government of India / State
    Government of _________________________________. Minimum qualification for admission to the course is a pass in
    ____________________ Examination.
    Certify that,the applicant has not applied for any other scholarship

    SEAL
    _____________________________________ Signature of Head of
    Institution
    Name (in Block Letter) :
    Designation :
    Address :
    State :
    Pin Code :
    Affiliation/Registration No.
    Government of West Bengal
    Office of the PO cum DWO, MALDAH District

    INCOME & RESIDENTIAL CERTIFICATE

    (Should be signed either by a Member of Parliament or Member of a State Legislature, or a Municipal Commissioner / Councillor /
    Member of Zilla Parishad / Member,GTA / Savapati of Panchayat Samity or a Government Officer. The issuing authority is
    requested to observe due caution as Scholarship is awarded on the basis of this very important Document.)
    Certified that the information furnished at point nos. 1 to 11 and 13 overleaf are correct to the best of my knowledge.
    Place ------------------------------

    Date ------------------------------

    SEAL Name (in Block


    Letter) :
    Designation :
    Address :
    State :
    Pin Code :

    DECLARATION OF INCOME

    (To be given by the parents/ guardians when the candidate is not employed)
    Certified that the gross annual income from all sources in respect of my family is Rs.____________ (Rupees
    _______________________________Only) one / two / three of my sons is / are availing such scholarships. I make myself
    responsible for the accuracy of the fact & figures furnished.I further undertake that in the event of the particulars given in the
    declaration being found false, I shall refund the whole amount of the Scholarship paid to the said Scholarship holder
    ______________________________ and the Government's decision in this regard shall be final and binding on me.

    Place ------------------------------
    Signature in full
    Date ------------------------------

    1. Applicant is to submit the ***computer-generated filled-in application form (duly signed) to the English Bazar Block
    Development Office. .
    2. Documents to be submitted along with computer generated application form:
    A. 1(One) Copy recent stamp size coloured photograph of the applicant duly attested and pasted on the application.
    B1. An attested copy of the caste certificate/Acknowledgement slip of the applicant(For prematric scholarship).
    B2. An attested copy of the caste certificate of the applicant(For postmatric scholarship).
    C. An attested copy of the marksheet/certificate of the last examination passed
    D. Copy of the first page of bank passbook(where the account number and bank details is mentioned).
    E. Copy of Identification Proof.
    3. The required certificates on the body of the application form are to be provided by the concerned authorities /persons.
    4. The application form has to be submitted by 30/11/2021.

    Application Date:-

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