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Backward Classes & Minorities Welfare Dept.

Fresh Application

Madhya PradeshScholarship Portal 2.0


Integrated Scholarship Application form- Post Matric Scholarships for year

2014-15

Applicant Code : 1031875


Application Number : 242539

Scheme : Post Metric Scholarship for OBC

Lock Date: 11/03/2015 IPAddress : 123.63.70.189


Version No: 3
Verification Code: 1960
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 sigh in it.
Previous Year Scholarship Details

1. Personal Details

SAMAGRA ID : 131911433

Name : AMIR HUSAIN

Gender :

No Scholarship sanctioned last year

Aadhaar No : 801036970569

As per SAMAGRA: Amir Husain

Male

Religion :

As Per Board Marksheet : AMIR HUSAIN

Special Category :

Muslim

Father's Name : IQBAL HUSAIN

As Per Board Marksheet : IQBAL HUSAIN

Mother's Name : MAHIRA IQBAL


HUSAIN

As Per Board Marksheet : MANTRA IQBAL HUSAIN

Date of Birth :

21/12/1989

2.Category OBC

No

As Per Board Marksheet : General

Admission Date :

3.Academic Details

Course :

As Per Board Marksheet : 21/12/1989

Caste Certificate : No: 00 Issued by :SDM HUZUR On :07/08/2008

Institute :

15/08/2014

Enrollment No. :

0183ME14MT03

Radha Raman Institute of Research, & Technology, Bhopal District: BHOPAL


M.E/M.Tech [Full Time]/Thermal Engineering/1Yr

Hostel Admission Date: Non-Hosteler


10th Board Name: MP Board of Secondary Education, Year: 2005-06, Roll No.: 166339822

4. 10th Board Details

5. Last Year Exam Details :

Exam Name: B TECH, Exam Date : 08/06/2012

School./Institute :SWAMI VIVEKANAND COLLEGE OF SCIENCE AND TECHNOLOGY

6. Total Annual Family Income :

Result : PASS

Rs.36000/-

Income Certificate issued by-TEHSILDAR On : 14/10/2014


7 Contact Details

Mobile No :

Correspondance Address :

8871112029

amirhusain2112[AT]gmail[DOT]com

53 Ziya manzil saeediya school road Itwara Bhopal, District :- BHOPAL

Permanent Address :
53 Ziya manzil saeediya school road Itwara Bhopal, District :- BHOPAL
8. Bank Account No: 21710100022210, IFS Code: BARB0KOTRAS, BANK OF BARODA, KOTRA-SULTAN-BHOPAL,

BHOPAL
]fDeclaration from Student and his Parent
We, AMIR HUSAIN S/o IQBAL HUSAIN and IQBAL HUSAIN hereby declare that Board Roll No, Samagra ID, caste certificate and income
certificate, bank account details and all other information given in the application form is complete and correct. We have not submitted any other
application for scholarship for current academic year in any other institution in India. We also undertake that, if any information given above is found to
be false at any stage, entire amount of scholarship will be recovered and competent authority will be free to initiate legal penal action against us.

AMIR HUSAIN S/o IQBAL HUSAIN kIQBAL HUSAIN `f]_CB


[[]\`\[f@][^
ff]@\`_]f
f[@

(Signature of Parent /  Date

(Signature of Student / ]

Delcaration from Institute Head & Institute Scholarship Nodal Officer


We, hereby, certify that the student is enrolled in the approved course of Govt MP. All the details filled by the student in the above application
form have been verified with the original documents and have been found to be correct and authentic. He has passed last exam and is eligible for
sanction of scholarship. College has ORIGINAL COPY of his School Leaving Certificate. His attendance is regular, as per the instructions of
Government
We have verified all details as per te 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 the matter to the
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 action against the institute.
(Signature of Institute Scholarship Nodal Officer)

Date

(Signature of Institute Director/Prinicpal)

Generated by Scholarship Portal as on 3/11/2015

Fresh Application

Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0


Integrated Scholarship Application form- Post Matric Scholarships for year

2014-15

Applicant Code : 1031875


Application Number : 242539
Version No: 3

Scheme : Post Metric Scholarship for OBC

Verification Code: 1960

Lock Date:

11/03/2015

IPAddress : 123.63.70.189

Your 10th Board Details 10th Board Name: MP


Board of Secondary Education, Year: 2005-06, Roll
No.: 166339822

Caste Certificate Details No: 00 Issued by :SDM


HUZUR On :07/08/2008

ALERT: Details of Applications already registered by using same Samagra ID :


Nil
ALERT: Details of Applications already registered by using same 10th Board Roll No :
Nil

(Signature of Parent /  Date

(Signature of Student / ]


Generated by Scholarship Portal as on 3/11/2015

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