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GOVERNMENT OF ANDHRA PRADESH MINORITIES WELFARE DEPARTMENT APPLICATION FOR PRE MATRIC SCHOLARSHIP FOR MINORITIES FOR THE ACADEMIC YEAR 20___ TO 20___ Renewal

/Fresh

Unique. ID No:

Registration No.: _________________ 1.Name of the student: 2.Father’s/Guardian’s Name: 3.Community:Muslim 4.Sex :

Male

Christian

Sikh

Buddhist

Parsi

Female Date

Month

Year

5.Date of Birth : (as per School Record) 6.Permanent Address: ________________________________ House No. _______________

Locality ______________

Village/Ward ______________ Constituency_____________

Mandal/Municipality/____________ Town/City District _________________

Pincode _______________

State _________________

Phone No:_________ 7.Present Address: ________________________________ House No ________________

Locality ______________

Village/Ward _______________ Mandal/Municipality ____________ Town/City Constituency_____________ Pincode ______________

District ____________________ State _________________

Phone No._____________

8. Physically Challenged: Yes

No

9. i) Total Annual income of Parents/ Guardian:____________________ ii) Ration Card Type White

Pink

10. Received any Scholarship amount (previous year): Yes/No ______ If Yes furnish Uniq Id. No. __________________________ 11. Details of present Class of Study a) Name of the Class:______________ b)Admission No: __________ c) Medium of Course : English Telugu

-212. Name of the School: ___________________________________________ a) Address: ______________________b) Village/Ward _______________ c) Mandal/Municipality/_________________ d) Constituency _________________ Town/City e) District _________________ f) Phone No: ________________________ 13. Status of School: a) Government

b) Government Aided :

c) Private (Recognized) 14. Previous Examination Passed (Class) a) Total Marks Obtained

b) Percentage of Marks

15. Total Annual Course Fee ______________ a) Admission Fee

b) Tuition Fee

16. Details of Student’s bank Account

a) Name of the Student (as in the Bank Account) b) Name of the Bank c) Bank Branch (full address)___________________________ State__________ District_____________Pin____________ d) Branch Code No._______________ e) Bank Account No._________________ (In words________________________________________) f) Type of Bank Account_________________ Saving/Current g) MICR code of the Bank__________________ h) Mode of Electronic transfer available in the Bank_____________ IFSC/ECA/RTGS/NEFT/CBS/Code Number (if any) Declaration of the Student

I hereby affirm that the above details entered in the application submitted through online are correct & true and that I will be liable for prosecution if any information furnished above is found incorrect/False. Signature of the Applicant.

Signature of the Parent.

Date: Income Certificate (To be certified by Tahasildar) This is to certify that Master / Kum. ______________________________ S/o. D/o _____________________________ Resident of __________________ Village ___________________ Mandal ________________________District. His/Her Parent /Guardian’s Name Sri___________________________ income is Rs. ___________________ per annum and belongs to __________ Community. Place: Date:

Signature of Tahasildar (With Seal)

-3Study / Bonafide Certificate (To be Certified by the Head Master)

Photograph Attested by Head Master

This is to certify that Master /Kum._____________________ S/O.,D/o. _______________________ Resident of ______________ Village ___________________ Mandal is studying _______________ course in our School During the Academic Year _______ belongs to _________Community as per the information of the School Records.

a) Bank Account No. of the School: b) Name of the Bank & Branch c) Bank Branch (full address) __________________________ State__________ District_____________Pin____________ d) Branch Code No._______________ e) Bank Account No.________________ (In words________________________________________) f)Type of Bank Account_________________ Saving/Current g) MICR code of the Bank__________________ h) Mode of Electronic transfer available in the Bank_____________ IFSC/ECA/RTGS/NEFT/CBS/Code Number (if any)

Reorganization No.

Signature of Head Master

Date:

(With Institution Seal)

Verification Report I have verified the contents of the application and also the School Records and found that the certification made by the Head master concerned is correct to the best of my knowledge.

Mandal Education Officer/ Dy. Inspector of School

Note: For details of scholarship eligibility please see in our Web site:“ www.apsmfc.com”

Enclosures: 1) 2) 3) 4) 5) 6)

Income Certificate issued by Tahasildar Bonafide Certificate Xerox Copy of Bank pass book in the name of Student Xerox copy of Previous year marks certificate(Progress report) Receipt of the Annual course fee. Date of Birth proof certificate (as per school record)