GOVERNMENT OF ANDHRA PRADESH DEPARTMENT OF SOCIAL WELFARE APPLICATION FOR POST-MATRIC SCHOLARSHIP FOR SCHEDULED CASTES & DALIT CHRISTIANS College Name & Place: -----------------------------------------------------Govt./Aided/Pvt. Mandal : --------------------------------------------- District: ----------------------------------------- College Admission Number: ----------------------- Date of admission:-------------------- Academic Year ----------------- Course: ------------------------- Year (1st/2nd/3rd/4th/Final): ------------------------- 1. Full Name (in Block Letters) : ---------------------------------------- (To be filled by the candidate) (Surname) (Name) 2. Father's Name : --------------------------------------- 3. (a) Guardian's Name (if father and mother are not alive)-------------------------- (b) Spouse's Name (for married candidate)---------------------------------------------- 4. (a) Present Postal Address -------------------------------------------- -------------------------------------------- (b) Permanent Address -------------------------------------------- -------------------------------------------- 5. (a) Whether passed-SS/CBSC/ICSC/MATRIC/Other State Board ---------------------- (b) Regd./Hall Ticket number of SSC or Equivalent Exam passed with month and year of Passing ---------------------------- 6. Date of Birth (as shown in Xth class Memo) --------------------------- 7. Sex (Male / Female) -------------------------------- 8. Nationality & Relation --------------- 9. Community (Scheduled caste/Dalit Christian) ------------------------------------------------ 10. Sub Caste (with Group) -------------------------------------- 11. Year of passing in the Previous Course ------------------------------------------------------ 12. Details of Present Course of Study (a) Name of the Course : (b) Duration (No. Years) : (c) From _________________ (month) To ____________________(month) 13. Place of Present Residence 14. Distance between College and Residence : KMs 15. Family Annual Income : Rs. 16. (a) Family Ration Card No.:/Electoral roll number of parent ------------------------- 17. Date of Admission in College Attached Hostel (if so) --------------------------------- 18. (a) Student's Bank A/C.No. : ------------------------------------------- (b) Name of the Bank & Branch : ------------------------------------------- 19. Year wise study particulars SSC onwards (specify if any gap is there in studies): Sl.No. Year of Study Course of Study Result % of Marks Name and address of school/college. It is to declare that the above information is true and correct. If it is proved to be false we will be held responsible and action can be initiated against us. Signature of the Signature of the candidate Parent/Guardian/Husband. ( To be filled by the Educational Institution ) The contents of the application have been verified with reference to the original documents submitted by the candidate to the institution and the photocopies of the same are enclosed herewith. Encl: 1. Copy of integrated caste certificate. 2. Copy of the Income certificate. 3. Copy of SSC marks memo. 4. Copy of the certificate / Marks memo of the course last studied. 5. Copy of transfer certificate of previous course. Tel. No. Signature & Name Place : of the Principal of the Date : Educational Institution. Seal. VERIFICATION REPORT OF ASSISTANT SOCIAL WELFARE OFFICER I verified the contents of application and also college records and physically identified the student and hereby certify the following: 1. SSC/Other equivalent examinations Registrations No. Correct / Incorrect 2. Caste particulars Correct / Incorrect 3. Specify Previous Course Attended by Applicant --------------------------------------- 4. Present course of study & year ------------------------------------------------------------- 5. Indicate whether student is Local or Non Local ---------------------------------------- 6. a) Applicant is a boarder of DS/SMH/CAH b) The date of admission in CAH is Correct/ In correct 7. Caste __________________ Sub-Caste ____________________ 8. Occupation of Parent / Guardian / Husband ( incase of married women) ________ 9. Total family Income from all sources Rs.______________ 10. Distance between the residence and Institution _________________ 11. The College Admission No.___________________________________ The following original certificates verified and found. Transfers Certificate Correct / Incorrect SSC Memo Correct / Incorrect Caste Certificate Correct / Incorrect Income Declaration/Certificate Correct / Incorrect Gap Certificate (if any) Correct / Incorrect Specific Recommendation of ASWO for sanction of Post-matric Scholarship----------------------------------------------------------------------------------------------------------------------------ASWO to endorse on the original Xth Class certificate of Candidate indicating Date and Course of Sanction. Signature Asst.Social Welfare Officer Place : Seal: Date: * Strike off whichever is not relevant. The verifying Authority should fillup all the columns. ( To be filled by the office of the Deputy Director Social Welfare ) Scholarship sanctioned for the period from _________________ to _________________ Day Scholar / Boarder of Student Managed Hostel / Boarder of College Attached Hostel. (a) Maintenance Charges @ Rs. _________ PM for _______ months = Rs._________________ (b) Tuition Fee __________ (b) Special Fee ------------------- (c) Exam fee ------------------ (d) Other Fee (Specify) ------------------ (e) Total Fee ------------------------ (f) Total amount sanctioned -------------------------- Section Assistant. Superintendent. Deputy Director(SW)
