GOVERNMENT OF ANDHRA PRADESH MINORITIES WELFARE DEPARTMENT APPLICATION FOR POST MATRIC SCHOLARSHIP & FEE REIMBURSEMENT FOR MINORITIES FOR THE ACADEMIC YEAR 20___ TO 20___ Renewal /Fresh Registration No.: ____________ Uniq. Id No: 1.Name of the student: _____________________________________ (as entered in SSC Certificate or Equivalent Examination) 2.Father's/Guardian's Name: ________________________________ 3.Community:Muslim 4.Sex : Male Christian Sikh Buddhist Parsi Female 5.Date of Birth : 6. Registered No. of SSC or Equivalent Exam : ________________________ 7. Permanent Address: House No _________________ Locality _______________ Village/Ward _______________ Mandal/Municipality/__________________ Town/City District ____________________ Pincode ___________________ State ________________ Phone No: ____________________ 8. Present Address: House No. _________________ Locality ______________ Village/Ward _______________ Mandal/Municipality/___________________ Town/City Constituency________________ District ____________________ Pincode ___________________ State __________________ Phone No: ____________________ 9. Distance between the place of residence : ______K.Ms and place of study -2 10. Student Status : a) Day Scholar : b)Student Managed Hostel : c) College Managed Hostel 11. Physically Challenged: Yes No 12. i)Total Annual income of Parents/ Guardian:____________________ ii) Ration Card Type White Pink 13. Details of present course of Study a) Name of the Course:______________ b)Admission No: __________ c) Present year of the Course : I/II/III/IV/V d) Medium of Course : English Telugu 14.College Name : _________________________________________________ a) Address: House No._________ Locality ________ b) Village/Ward __________ c) Mandal/Municipality/_________________ d) Constituency ______________ Town/City e) District ____________________ F) Phone No:____________________ 15. i) Type of College: a) Government b) Government Aided : c) Private 16. Fee Particulars: a) Tuition fee per Annum: Rs. __________ b) Special Fee per Annum: Rs. ________ c) Examination Fee Rs.____________ d) Total Fees : Rs. _______________ (Enclose Fee receipt duly attested by the Head of the Institution) 17. 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) Note: For details of scholarship eligibility please see in our Web site: " www.apsmfc.com" Declaration of the Student I hereby affirm that the above details entered in the application submitted through online are correct and 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: CERTIFICATE FOR COLLEGE ATTACHED HOSTEL BOARDERS Certified that the above details have been verified and found true as per our records and if any information furnished is found wrong. We will be held responsible and liable for action as per rules. Signature of the of the Hostel Signature of the Head of Welfare Officer with stamp the Institution with Seal Study / Bonafide Certificate (To be certified by the Principal) This is to certify that Master /Kum.___________________________ S/O.,D/o. ____________________ Resident of ____________ Village ___________ Mandal is studying _________________ course in our Photograph attested by Principal College during the Academic year __________ belongs to ______Community as per the information of the College Records. a) Bank Account No. of the Institution: 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) Recognisation No. Signature of Principal Date: (With Institution Seal) 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: Signature of Tahasildar Date: (With Seal) Enclosures: 1) Xerox copy of acknowledgement ( computer generated slip) 2) Xerox copy of S.S.C. Marks Memo 3) Bonafide Certificate from College 4) Xerox copy of Fee receipts 5) Entrance Exam Rank Card 6) Bank Pass Book Xerox 7) Income Certificate issued by Tahasildar
