ApplicantForm

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Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2021-22
Applicant Unique ID : 3728353
Scheme : Post Metric Scholarship for OBC
Application ID: 6940301
Version No: 1 Verification Code: 9004 Lock Date: 17/09/2022 IPAddress : 106.201.244.233
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 : 137902977 Aadhaar No : XXXXXXXX1466 Voter ID : --
Name : DURGESH NAGAR As per SAMAGRA: DURGESH NAGAR AS Per Board Marksheet : DURGESH NAGAR
Gender : Male Religion : Hindu Special Category : No
Father / Husband Name SHREE AS Per Board Marksheet : LAXMINARAYAN NAGAR
: LAXMINARAYAN JI
NAGAR
Mother's Name : MATHURA DEVI AS Per Board Marksheet : MATHURA DEVI
I O
Date of Birth : 05/03/1999 AS Per Board Marksheet : 05/03/1999
2.Category OBC
Caste Certificate : Reg No : RS/442/0106/55093/2015, Name : DURGESH NAGAR, Father Name : LAXMI NARAYAN I O
NAGAR, Mother Name :MATHURA DEVI, Category : OBC, Caste :Dhakad
3.Academic Details Admission Date : 12/02/2022 Enrollment No. : AP015A000018015 I O
University/Board Name : Madhya Pradesh Medical University, Jabalpur
Institute : 39144-Parashar Ayurvedic Medical College and Hospital District: BHOPAL
Course : 9003/BAMS/BAMS (Ayurved)/3rd Year
Hostel Status: Days Scholar , , Hostel Type : Day Scholar
4. 10th Board Details 10th Board Name: MP Board of Secondary Education, Year: 2012-2013, Roll No.: 136119158
5. Last Year Exam Details : Exam Name: 9003/BAMS/BAMS (Ayurved)/2nd Year, Exam Date : 11/05/2022 I O
School./Institute :Parashar Ayurvedic Medical College and Hospital Result : Promoted to next higher Course Year
(Pass/ATKT)
6. Total Annual Family Income : Rs.40000/-

Income Certificate issued by-Revenue Department On : 25/01/2022
7 Contact Details Mobile No : 9893034120 ddhakad638[AT]gmail[DOT]com I O
Correspondance Address : , District :- RAJGARH
Permanent Address : , District :- RAJGARH

8. Bank Account No: 20398722784, IFS Code: SBIN0030195, STATE BANK OF INDIA, UDANKHADI, RAJGARH I O
9. Previous Year Sanction Order Details Application ID : 5454852
I O
Sanction Order No.: 1319943, Sanction Order Date: 02/02/2022, Sanction Amount: Rs.48760/-
Generated by Scholarship Portal as on 13/12/2022

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]ȯfȲȡȧȪȡDeclaration from Student and his Parent
ɇDURGESH NAGAR s/w/o SHREE LAXMINARAYAN JI NAGAR ȪȡȡȢ¡ǗȱͩȡğǙǓȢȢȧhȡ^
]ȯȨ[ȯȣ_ Ȣȡȡǐɉǔ ȯǕÉǾ ȯȯȡȡȡȡͪȡȡȡ10th Board ȧȡȡȣȯ\Ǖ ȡ[Ǔ
Ĥȡğȯ\Ǖ ȡͧȲ]ȡȲ[ȡȣ¢ȡǐȡ] ȲȲȢȡȡȣ]Ĥȡğȯ\Ǖ ȡ[ȡȯ\Ú
Ȫ [Ȫ [ȡ[ɇȡȯĤȯȡĤȡfȲ Ȳèȡ ȲȲȢȡȡȣ ¡ȣfȲ ×¡ȰfȲȪ[èȡȯ«ȯǾȯ\Ȫȧ_¡Ȱ)
ɇ[ȡȰ¢ͨ ğȯȯf¡ȣĤȡȧèȨͧ[ȯͧf]ȯͩȡ¡Ǘȱ)Ǒ^ȯ ȯȪ_Ȣȡȡȣ\ ×ȡğǕǑǗ[ȡ_
ȡȢ¡ȰȪȯȡȡğǙǓ]ȯȡ[ ȲèȡèȢǙǓȡ[\ͬȡȣͪȡƮȡȡǓèͩfȡȯɇèȡȡ¡Ǘȱȡ¡ǗȱȢ)ȡ
ȯȯͪǽƨ¤ȡǗȢȡ[ȡ¡ȣȯȯͧfèȲğ¡Ȫȡ)
ɇȪ [Ǘ[¡Ȫȯȯ¡ȯȪ [ ȲèȡȪ°ȯȡȯȢ¡ǗȱȪ¡ȯȣǗ[ǔàȯȡȣ¡ȪȢͩȯȯƮȡȡǗ[Ʌ ȲȲͬȪ [ȯͧȯĤȡƯ
ȡğǙͪƣȡ Ȫ ȲȲͬǔȡȡȡ[ȯȡÚ ȯ ȡȡ ȯȡ ǗȲȡǗȲȢ)ȡğǙͪƣȡ ȯͩǔèǓɅȡ ȯȯ
ͪǾƨȪ_Ȣȡȡ[ȡ¡ȣȯȯͧȯèȲğ¡ȯȡ)
(Signature of Parent / ȡͪȡȯ¡èȡ¢ Date (Signature of Student / ]ȯȯ¡èȡ¢
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

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Previous Year MarkSheet
Fees Receipt/ Admission Slip
(Signature of Parent / ȡͪȡȯ¡èȡ¢ Date (Signature of Student / ]ȯȯ¡èȡ¢
Ȫȡğȡğȡȯ]ȯȨ[Ǒ¢ȡȢȡͪ`Þ¡ȣȲ¡Ȫȯ ȲèȡĤǕȡğȡğȡȯȢȧǗĤǓ ȡ[Ȣ ȯ

ȡȡȣ ×ȡͪȯ)
Ǒ]Øɉȯ]ȡȡğǙǓȯȯ¡Ǖ]ȡfȯȪ]ȧȡğǙͪƣǓèȣȡȯȢȡȡğǙͪƣȧǔȢȣ_¡Ȱ` ȯ
ȡ ȯȣȡȯȢ)^ ¡ȯͩĐȡȡ ȯ ǔÛͪȡȸȪ¡ȯȡȯͧfͩ ȢȢȪȡȯ\Û[ͩ ȢȢȡğǙͪƣ ȯͪǔ[(Debarred)
ǑȡȡȯȡȡͪȡȸȪȡȣ Ǘ Ȣ(Black List) ɅȡǑȡȡȯȡȡȡğǙͪƣèȢǙȡ[\ͬȡȣ\ȡ\Û ¢\ͬȡȣ]æ
ȯɅȪ` ȯͪǽÚȡȢÖ ȲǑ¡ȡȧȡȡjȲfȲȯ¡f]_][ȡ_ȡ Éȡ[ȡ¡ȣȧ
ȡȯȢ)

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Ȫ\]ȪȪ_ èȡ¡ȰȪ]\ȯǔȯȯȡȡ[ȯÈǔȡBHOPAL ȯ ͪ°ȡ[ãȡ

Ʌ Ȳ[ ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

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

Permanent Address : , District :- RAJGARH

Generated by Scholarship Portal as on 13/12/2022

Renewal Application Backward Classes & Minorities Welfare Dept.

(Signature of Parent / ȡͪȡȯ¡èȡ¢ Date (Signature of Student / ]ȯȯ¡èȡ¢

Declaration from Institute Head & Institute Scholarship Nodal Officer

(Signature ) (Signature ) Date (Signature )

Income Certificate Details

Generated by Scholarship Portal as on 13/12/2022

Renewal Application Backward Classes & Minorities Welfare Dept.

Previous Year MarkSheet

Fees Receipt/ Admission Slip

(Signature of Parent / ȡͪȡȯ¡èȡ¢ Date (Signature of Student / ]ȯȯ¡èȡ¢

Ȫȡğȡğȡȯ]ȯȨ[Ǒ¢ȡȢȡͪ`Þ¡ȣȲ¡Ȫȯ ȲèȡĤǕȡğȡğȡȯȢȧǗĤǓ ȡ[Ȣ ȯ

Generated by Scholarship Portal as on 13/12/2022

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Renewal Application Backward Classes & Minorities Welfare Dept.

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

Permanent Address : , District :- RAJGARH

Generated by Scholarship Portal as on 13/12/2022

Renewal Application Backward Classes & Minorities Welfare Dept.

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Declaration from Institute Head & Institute Scholarship Nodal Officer

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Income Certificate Details

Generated by Scholarship Portal as on 13/12/2022

Renewal Application Backward Classes & Minorities Welfare Dept.

Previous Year MarkSheet

Fees Receipt/ Admission Slip

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Generated by Scholarship Portal as on 13/12/2022

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(Signature of Parent / ȡͪȡȯ¡èȡ¢ Date (Signature of Student / ]ȯȯ¡èȡ¢

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