“ȪŠ\‚š]”€Ȫ€Ȫ_ ˜è™ȡ¡ȰȪ]”\”“ȯǔ‡›ȯ€ȯ€ȡ™ȡ[›™€›ȯȊšǔ‡›ȡREWA €ȯ ͪ”†°ȡ‚[€ã™ȡŽ

˜Ʌ Ȳ”€[€š €ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2019-20
Applicant Unique ID : 2336817
Scheme : Post Metric Scholarship for OBC
Application ID: 4400954
Version No: 1 Verification Code: 5266 Lock Date: 17/10/2019 IPAddress : 49.36.24.220
Instructions for colleges & offices: Please check all information in each section and place a tick mark in on the box. Institute will use the first Box
with I sign and Sanctioning Office will use second box with O sign in it.
1. Personal Details SAMAGRA ID : 180297276 Aadhaar No : XXXXXXXX2496 Voter ID : --
Name : PRIYANKA PATEL As per SAMAGRA: PRIYANKA PATEL
Gender : Female Religion : Hindu Special Category : No
Father's Name : RAJENDRAPATEL ** Colleges / District Offices are requested to verify Board name,Passing year
and Roll No. from student original 10th Marksheet
Mother's Name : SAVITRIPATEL
I O
Date of Birth : 05/04/1998

2.Category OBC
Caste Certificate : No: RS/430/0106/4317/2015 by :Tehsil Office Gurh On :23/03/2015 I O
3.Academic Details Admission Date : 30/07/2019 Enrollment No. : 152071580206 I O
University/Board Name : Not Available
Institute : 16542-Govt Thakur Ranmat Singh College, Rewa District: REWA
Course : 1044/M. Sc./Chemistry/2nd Year
Hostel Status: Day Scholar

4. 10th Board Details 10th Board Name: MP Board of Secondary Education, Year: 2012-13, Roll No.: 133237757

School Scholarship Details Generated From Samagra Portal

Name : PRIYANKA PATEL Category : OBC DOB : XXXXXX1998 Gender : Female
Father Name : RAJENDRA PATEL BPL : “¡ȣȲ CWSN : No

Sno Academic Year School Current Class

1 2014-15 HSS Khajuha 12 th
2 2013-14 HSS Khajuha 11 th

5. Last Year Exam Details : Exam Name: 1044/M. Sc./Chemistry/1st Year, Exam Date : 16/02/2019 I O
School./Institute :Govt Thakur Ranmat Singh College, Rewa Result : Promoted to next higher Course Year
(Pass/ATKT)

6. Total Annual Family Income : Rs.40000/-

Income Certificate issued by-Revenue Department On : 05/10/2018
7 Contact Details Mobile No : 9109778954 PRIYANKAPATEL1998REWA[AT]GMAIL[DOT]COM I O
Correspondance Address : VILLAGE POST KHAJUHA KALA TEHSIL GURH, District :- REWA

Permanent Address : VILLAGE POST KHAJUHA KALA TEHSIL GURH, District :- REWA
8. Bank Account No: 586902010007436, IFS Code: UBIN0558699, UNION BANK OF INDIA, SHILPI PLAZA, REWA, I O
REWA
9. Previous Year Sanction Order Details Application ID : 3709977
I O
Sanction Order No.: 1207298, Sanction Order Date: 17/06/2019, Sanction Amount: Rs.24153/-

Generated by Scholarship Portal as on 17/10/2019

“ȪŠ\‚š]”€Ȫ€Ȫ_ ˜è™ȡ¡ȰȪ]”\”“ȯǔ‡›ȯ€ȯ€ȡ™ȡ[›™€›ȯȊšǔ‡›ȡREWA €ȯ ͪ”†°ȡ‚[€ã™ȡŽ
˜Ʌ Ȳ”€[€š €ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2019-20
Applicant Unique ID : 2336817
Scheme : Post Metric Scholarship for OBC
Application ID: 4400954
Version No: 1 Verification Code: 5266 Lock Date: 17/10/2019 IPAddress : 49.36.24.220
]ȯ‘€fȲ”ȡ›€€ȧƒȪŸŽȡDeclaration from Student and his Parent
˜ɇPRIYANKA PATEL s/w/o RAJENDRAPATEL ƒȪŸŽȡ€šȡ€šȢ¡Ǘȱͩ€†ȡğǙǓ“Ȣ“Ȣ€šŽ€ȧh“›ȡ^“]ȯ‘“•Ȩ˜[˜ȯ—šȣ
‚_ —Ȣ‡ȡ“€ȡǐš™ɉǔ‡ ˜ȯ˜ǕəǾ” ȯ˜ȯšȡ“ȡ˜˜ȡȡͪ”ȡ€ȡ“ȡ˜10th Board €ȧ‡ȡ“€ȡšȣ€ȯ\“Ǖ ȡš‚[‡ǓĤ˜ȡŽ”ğ€ȯ
\“Ǖ ȡšͧ›Ȳ‚]’ȡš“Ȳ‚Ÿ[€ȡ”šȣ¢ȡ”ǐšŽȡ˜]™ Ȳ–Ȳ’Ȣ‡ȡ“€ȡšȣ]™Ĥ˜ȡŽ”ğ€ȯ\“Ǖ ȡš[˜ȡ“˜ȯ\ڙ™“š€Ȫ [€Ȫ [€ȡ
Ÿ[–ɇ€ȡȯĤȯž€ȡĤ€ȡšfȲ Ȳèȡ Ȳ–Ȳ’Ȣ‡ȡ“€ȡšȣ ¡ȣfȲ ×™¡ȰfȲ”ȪŠ[›”š‘èȡȯ«€ȯǾ”˜ȯ\”›ȪŒ€ȧ‚_¡Ȱ)˜ɇ[˜ȡ“
žȰ¢ͨŽ€ ğ˜ȯ€ȯ›f€¡ȣĤ€ȡš€ȧè€Ȩ›ͧž[”€ȯͧ›f]ȯ‘“ͩ€™ȡ¡Ǘȱ)™Ǒ‘^“˜ȯ ȯ€Ȫ_—Ȣ‡ȡ“€ȡšȣ\ ×™™ȡğǕǑŠ”ǗŽ[”ȡ_‡ȡȢ¡ȰȪ
˜ȯšȡ†ȡğǙǓ]ȯ‘“•ȡ˜[ ȲèȡèȢ€ǙǓ€ȡ[\ͬ’€ȡšȣͪ—ȡ‚ƮȡšȡǓ“šèͩ€f‡ȡ“ȯ”š˜ɇ蝙‡–ȡ–‘ȡšš¡Ǘȱ‚ȡš¡Ǘȱ‚Ȣ)žȡ “˜ȯšȯͪǽƨ
¤ȡ“Ǘ“Ȣ€ȡ™[ȡ¡ȣ€š“ȯ€ȯͧ›f蝏Ȳğ¡Ȫ‚ȡ)
˜ɇ€Ȫ [”ǗŽ[¡Ȫ“ȯ€ȯ”¡›ȯ€Ȫ [ Ȳèȡ†Ȫ°‘ȯȡ‘ȯȢ¡ǗȱȪ™¡˜ȯšȣ”ǗŽ[ǔ‡à˜ȯ‘ȡšȣ¡Ȫ‚Ȣͩ€˜ȯšȯƮȡšȡ”Ǘ[˜Ʌ Ȳ–Ȳͬ’€Ȫ [€ȯͧ›™ȯĤȡƯ
†ȡğǙͪƣžȡ “€Ȫ Ȳ–Ȳͬ’ǔ‡›ȡ€ȡ™ȡ[›™€ȯ˜ȡڙ˜ ȯ…ȡ›ȡ“ ȯȡ” €š‘ǗȲ‚ȡ‘ǗȲ‚Ȣ)†ȡğǙͪƣȡ” “€š“ȯͩ€ǔèǓ˜Ʌžȡ “˜ȯšȯ
ͪǾƨ€Ȫ_—Ȣ€ȡ™ȡ[ȡ¡ȣ€š“ȯ€ȯͧ›™ȯ蝏Ȳğš¡ȯ‚ȡ)

(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

Declaration from Institute Head & Institute Scholarship Nodal Officer

We, hereby, certify that student is enrolled in college in the course approved/recognized by concerned board/council/university. All details filled
by student in above application form have been verified with original documents & have been found to be correct / authentic. Applicant has
promoted to next higher course year(Pass/ATKT). College has ORIGINAL COPY of his Transfer Certificate. Applicant is not enrolled in another
institute. Applicant's attendance is regular.
We have verified all details as per scheme guidlelines & instructions and recommend him for sanction of scholarship as per the rules. We also
undertake that, if the above student does not attend the classes regularly or discontinues the course, We will immediately report it on portal and
to concerned district office so that his scholarship can be put on hold. In case any information of found to be incorrect, Government will be free to
initiate legal and penal action against the institute.

(Signature ) (Signature ) Date (Signature )

Scholarship Nodal Officer HOD Director/Prinicpal

Income Certificate Details

Generated by Scholarship Portal as on 17/10/2019

“ȪŠ\‚š]”€Ȫ€Ȫ_ ˜è™ȡ¡ȰȪ]”\”“ȯǔ‡›ȯ€ȯ€ȡ™ȡ[›™€›ȯȊšǔ‡›ȡREWA €ȯ ͪ”†°ȡ‚[€ã™ȡŽ
˜Ʌ Ȳ”€[€š €ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2019-20
Applicant Unique ID : 2336817
Scheme : Post Metric Scholarship for OBC
Application ID: 4400954
Version No: 1 Verification Code: 5266 Lock Date: 17/10/2019 IPAddress : 49.36.24.220

Previous Year MarkSheet

Fees Receipt/ Admission Slip

(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

“ȪŠ†ȡğ†ȡğȡ€ȯ]ȯ‘“•Ȩ˜[”š™Ǒ‘€¢ȡȢ€ȡͪšŽ`”›Þ’“¡ȣȲ¡Ȫ“ȯ”š ȲèȡĤ˜Ǖ†ȡğ†ȡğȡ€ȯȢ€ȧ˜Ǘ›ĤǓ
˜ȡ€[žȢŠ ȯ
‡ȡ“€ȡšȣ ×™ȡͪ”€šȯ)
™Ǒ‘]”‚›Ø™ɉ€ȯ]’ȡš”š†ȡğǙǓ›ȯȯ¡Ǖ]”ȡf‚™ȯȪ]”€ȧ†ȡğǙͪƣǓ“šè€š‘ȣ‡ȡȯ‚Ȣȡ†ȡğǙͪƣ€ȧǔ‡“Ȣš€˜‘ȣ‚_¡Ȱ` ȯ
ȡ” ›ȯ›ȣ‡ȡȯ‚Ȣ)^ š¡€ȯͩЙȡ€›ȡ” ȯ ˜ǔےͪ’ȡȸ€Ȫ¡˜ȯžȡ€ȯͧ›fͩ€ Ȣ—Ȣ™Ȫ‡“ȡ€ȯ\ۏ‚[ͩ€ Ȣ—Ȣ†ȡğǙͪƣ ȯͪǔ‡[(Debarred)
€šǑ‘™ȡ‡ȡ™ȯ‚ȡȡͪ’ȡȸ€Ȫ€ȡ›ȣ Ǘ…Ȣ(Black List) ˜ɅŒȡ›Ǒ‘™ȡ‡ȡ™ȯ‚ȡȡ†ȡğǙͪƣèȢ€Ǚ€ȡ[\ͬ’€ȡšȣ\ȡ\ۙ ¢˜\ͬ’€ȡšȣ]æ™€
 ˜ˆȯ‚ɅȪ` €ȯͪǽڑ—ȡšȢ™‘ÖŒ ȲǑ¡ȡ€ȧ’ȡšȡjȲfȲ€ȯ¡f•]_]š‘‡[€šȡ_‡ȡ€š É€ȡ™[ȡ¡ȣ€ȧ
‡ȡȯ‚Ȣ)

Generated by Scholarship Portal as on 17/10/2019