GOVERNMENT OF ANDHRA PRADESH, MINORITIES WELFARE DEPARTMENT

APPLICATION FOR STATE GOVERNMENT POST MATRIC SCHOLARSHIP

FOR MINORITIES

IDENTIFICATION DETAILS
TOKEN NUMBER 80716 DATE OF RECEIPT 2009-07-29
NAME OF THE STUDENT (AS PER
SSC )
SHAIK BUDDUBHAI SANDHANI
DATE OF BIRTH (AS PER SSC) 1990-06-01 FATHER’S/GUARDIAN’S NAME GOUSHMOHIDDHIN
PARENT/PARENT’S
GENDER Male OCCUPATION kooli
TOTAL ANNUAL INCOME OF
COMMUNITY/RELIGION Muslim 18000
FAMILY
APPLICATION Renewal SSC OR EQUIVALENT EXAM SSC
REGISTERED NO. OF SSC/ YEAR OF PASSING
2005
EQUIVALENT EXAM 0460739 ( SSC OR EQUIVALENT EXAM)
TYPE OF RATION CARD White PHYSICALLY CHALLENGED No
DETAILS OF PRESENT COURSE OF STUDY
UNIVERSITY NAME SRI VENKATESHWARA UNIVERSITY
DISTRICT WHERE MANDAL/TOWN/CITY WHERE
NELLORE UDAYAGIRI
COLLEGE LOCATED COLLEGE LOCATED
COLLEGE NAME GOVT. DEGREE COLLEGE, Udayagiri
B.A. GENERAL
COURSE NAME Graduation SUBJECT
COURSES
MEDIUM OF COURSE Telugu PRESENT YEAR OF STUDY 2
NAME OF COMPETITIVE WINDOW SW1/SW2 (UNDER WHICH
No
EXAM ADMITTED)

ENTRANCE HALL
ENTRANCE RANK 0
TICKET NO
CATEGORY OF
ADMISSION ADMISSION NO OF COLLEGE 1452
DISTANCE B/W RESIDENCE AND
STUDENT STATUS DS COLLEGE 30
DETAILS OF PREVIOUS COURSE OF STUDY
PREVIOUS EXAMINATION
YES TOTAL MARKS 1000
PASSED
PERCENTAGE OF
MARKS OBTAINED 637 63
MARKS OBTAINED

BANK DETAILS
NAME OF THE DISTRICT IN WHICH BANK
NELLORE
LOCATED
NAME OF THE BANK Syndicate Bank
BRANCH SYNB0003470
BANK ACCOUNT NO. OF THE STUDENT 3470 - 221 - 8624
PRESENT ADDRESS / ADDRESS OF CORRESPONDENCE
2-68, HOUSE, ROSEDAR STREET, ---------, ---------,
ADDRESS
UDAYAGIRI
STATE ANDHRA PRADESH DISTRICT NELLORE
UDAYAGIRI @
MANDAL/TEHSIL/TOWN/CITY UDAYAGIRI VILLAGE
KONDAYAP
EMAIL skeriton@yahoo.com MOBILE NO. 9642665483
RESIDENCE PHONE
PIN CODE 524226 8620229228
NO.
ASSEMBLY CONSTITUENCY UDAYAGIRI
PERMANENT ADDRESS IS SAME AS PRESENT ADDRESS

STUDY/BONAFIDE CERTIFICATE Photograph

Attested by
(TO BE CERTIFIED BY THEPRINCIPAL) Principal

This is tocertify that Master/Kum._________________________________

S/O.,D/o._______________________ Resident of ___________________
Village___________________ Mandal is studying __________________ course
_______ year inour College during the Academic Year __________. He/She got
Admission inConvener Quota i.e. `A` Category/`B` Category/Management Quota.
He/She belongsto_______ Community as per the information of the College
Records and is a Dayscholar/ Hosteller.
a) Bank Account No. of theCollege __________________________
b) Name of the Bank______________________________________
c) Name of the Branch_____________________________________
d) IFSC CodeNumber______________________________________
(Nationlised Banks only)
Institution RecognizationNo:_________ Year:________ Valid Up to:_______ Year
Date:

Signature ofPrincipal
(With CollegeSeal)
SIGNATURE OF THE STUDENT
SIGNATURE OF THEPARENT/GUARDIAN
 SIGNATURE OF THEVERIFICATION OFFICER

(ASWO/ABCWO/ACWO)(OFFICE USEONLY)

DOCUMENTS TO BEENCLOSED
1. .Income Certificate issued byTahsildar.
2. Xerox copy of S.S.C orequivalent course Marks Memorandum Attested by the
Principal.
3. Xerox copy of Previous Course(Class) Marks list, Attested by the Principal.
4. Bonafide Certificate issued bythe Institution.
5. Proof Of Permanent Residence(residence (Xerox copy of Ration Card/Voter
ID/Electricity Bill/Gas Bill or anyother document of Father/Guardian).
6. Xerox copy of Bank A/c PassBook of the Student.
7. Photograph attested byPrincipal.
8. Details of Fee particulars andXerox copies of fee receipts.
9. Allotment Letter ofConvenor/Management
Application should be sentthrough the Educational
Institutions only
FOR FURTHER DETAILS VISIT OURWEBSITEwww.apsmfc.com->