GOVERNMENT OF ANDHRA PRADESH DEPARTMENT OF BACKWARD CLASSES WELFARE Application for Post-Matric Scholarships for BCs Renewal/Fresh 1. Name of the Student : (as entered in SSC Certificate or equivalent Examination) 2. Father's / Gaurdian's Name : (if father is not alive) 3. Native Place : 4. Date of Birth (as per SSC : Examination Certificate) 5. Registered No. of SSC or : (a) Equivalent examination (b) Month and year of passing SSC 6. Sex (M/F) : 7. Religion : 8. Caste : 9. Group (A/B/D) : 10. Present postal address of the : student (a) House No. (b) Village / Street (c) Town/Mandal (d) District. 11. Previous course of study : 12. Year of Passing of previous : course 13. Name of educational : institution where he/she last studied. 14. Details of present course of : study (a) Name of course (b) Present year of the course I/II/III/IV/V/VI/VII (c) Duration of the current years Study (i.e. from which month To which months) Attest Passport size photo to be asttested by the Principal 15. Name of the educational institution : 16. Is it a Government or Private : institution 17. Date of admission in the college : 18. Distance between the place of : residence and place of study 19. Annual Tuition fees : 20. Annual special fees : 21. Examination fees : 22. Other non-refundable fees : 23. Total fees : 24. Date of admission in the attached : Hostels 25. Mention details of any other : scholarships being received 26. Family Ration card No. Roll No. of : parent in gram panchayat electroral Roll. 27. Nearest Bank Branch (SBH/SBI) : (for out of state student only) I hereby affirm that the above details 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. 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 Warden of the Hostel with stamp. Signature of the Head of the Institution and stamp and seal of the institution. FORM-III Serial No. District Code S.C. Mandal Code S.T. Village Code B.C. Certificate No. COMMUNITY NATIVITY / AND DATE OF BIRTH CERTIFICATE: 1) This is to certify that Sri/Smt./Kum ________________________________________ Son/Daughter of Sri _____________________________ of Village / Town _______________________ Mandal _________________________ District _______________________ of the state of Andhra Pradesh belongs to _____________ Community which is recognized as SC/ST/BC under The Constitution of Scheduled Castes Order 1950 The Constitution of Scheduled Caste Order 1950 G.Ms. No. 1793. Education, Dated : 25.09.1970 as amended from time to time (BCs) SCs, STs list (amenededment) order, 1956 SCs and STs amendedment) Act, 1976. 2) It is to certified Sri/Smt./Kum _______________________________________________ is native of ______________________ of Village /Town _____________________________ Mandal _________________ District _______________________ of the state of Andhra Pradesh. 3) It is certified that date of birth of Sri/Smt./Kum ________________________________________ is day _______________________________ Month year (In words) ____________________________ as per the declaration given be his/her Father / Mother / Guardian and as entered in the school records where he / she studied. Date Signature of M.R.O. : Place : Name in Capital Letters Designation. INCOME CERTIFICATE This is to certify that the annual income of Sri/Srimati/Kumari _____________________________________ Son/Daughter/Wife ________________________ of village _________________ Mandal _____________ District ___________________ from all sources in Rs. _______________________ as shown below : Source of income Annual Income Lands : Rs. Buildings : Rs. Business : Rs. Salary of both wife and Husband if both are Employed : Rs. Labour : Rs. Total Rs. ( Rupees in words _______________________________________________________________________ only) Place : Signature Date : Name in capital letters : Office seal Designation
