Você está na página 1de 5

1

CHECK LIST OF DOCUMENTS TO BE ATTACHED WITH


THE APPLICATION FORM
Application Form of PM Scholarship of 2014-15 from Page 01 to 05 only. No other
documents will be accepted other than mentioned in the check list.
(a)
If student is born after discharge, then affidavit is to be submitted by ESM / ExCoast Guard.
(b)
Additional Certificates Additional certificate is to be attached in support of
the cat 1 to 5, as mentioned in brochure.
(c)
Attested photocopy of Matriculation or equivalent examination certificate for
verification of date of birth.
(d)
Attested photocopy of mark sheet of MEQ as applicable (e.g. 10 plus 2,
Graduation / Diploma). In case the MEQ is Graduation / Diploma, then mark sheets of
all semester are required to be submitted.
(e)
Bonafide Certificate to be signed by Registrar / Dean / Principal of College /
Institution pertaining to course for which scholarship is applied.
(f)
Photocopy of bank pass book (PNB / SBI only) showing the candidates
Account No & Name.

Date: _____________________

____________________________
Full Name & Signature of Candidate

Place: ____________________
__________________________________________________________________________
CERTIFICATE FROM RSB / DIRECTORATE GENERAL OF COAST GUARD
It is certified that Application Form for PM Scholarship for Academic Year 2014-15 in
respect of Mr. / Ms. __________________________________________________________
S/o / D/o Ex -____________________________________________________ has been
checked, found correct as per check list provided by KSB and the applicant is eligible to apply
as per rules of the scheme.
Office seal:
Place: ________________
Date : ________________

(Secy / Dir RSB / Coast Guard HQ)

2
Selection Serial Number
(To be allotted by KSB) ......................
APPLICATION FOR PRIME MINISTERS SCHOLARSHIP - 2014-15

Recent
Photograph
of Student

1.

Name of Student (in Capitals)

________________________________________

2.

Gender (tick)

Male / Female

3.

Date of Birth

4.

Marital Status (tick)

4.

Full Address (in Capitals)

________________________________________

(Correspondence Address)

________________________________________

________________________________________
-

Married / Unmarried

________________________________________
5.

E-mail ID of Student

________________________________________

6.

Contact No of Student

________________________________________

7.

Ex-Servicemen Category (See Para 7 of Brochure)

One / Two / Three / Four / Five / Six

8.

Ex-Servicemans / Ex-Coast Guards Particulars :-

9.

10.

(a)

Name of ESM / ECG

- ________________________________________

(b)

Service No __________________

(d)

Army / Air Force / Navy / CG

(c)

Rank ____________________

Details of MEQ / Course (10+2 or its Equivalent or Diploma / Graduation)


(a)

Name of Course (MEQ)

______________________________________

(b)

Percentage of Marks in MEQ ____________________________________

(a)

Name of Course for PM Scholarship__________________________________

(b)

Course commenced on _____________ (c) Course ending on _____________

11.

Name of College / Institute

___________________________________________

12.

Bank Account Number (SBI or PNB only) ________________________________


(Photocopy of Bank Pass Book to be enclosed)

3
13.
Details of Brother / Sister availing / availed the PMs Scholarship, if any.
(Including yourself if granted earlier)
Ser
No

Selection
Serial No.
given by KSB

Name of the
Brother /Sister/
Self

Course
of Study

Academic
Year in which
Applied

Amount
received so
far

14.
Declaration. Certified that the particulars given by me in the application are correct
and any false statement made by us will disqualify me / my ward for award of PMs
Scholarship, besides recovery of scholarship already paid. I also undertake to abide by the
conditions mentioned in the general instructions of the scheme.

(Signature of ward) _________________

(Signature of Parent) ________________

(Full Name of Ward) ________________

(Full Name of Parent) _______________

Date __________________
__________________________________________________________________________
FOR OFFICIAL (KENDRIYA SAINIK BOARD) USE ONLY
Remarks & Signature of Checking Clerk

_______________________________
_______________________________
_______________________________

Remarks &Signature of Supervisor/IC PMSS _______________________________


_______________________________
_______________________________
RECOMMENDED / NOT RECOMMENDED
Signature of JD PMSS

Remarks of JD PMSS

____________________

_______________________________
_______________________________
_______________________________

4
Annexure-1
SPECIMEN COPY OF EX-SERVICEMAN / EX-COAST GUARD CERTIFICATE
(This is an important document, fill it carefully)
(In lieu of Discharge Book)
1.

Type of Service
(Army, Navy, Air Force or Coast Guard)

: _______________________________________

2.

Service No

: _______________________________________

3.

Rank

: _______________________________________

4.

Name & Initials

: _______________________________________

5.

Trade

: _______________________________________

6.

Date of Enrolment

: _______________________________________

7.

Date of Discharge

: _______________________________________

8.

Reason for Discharge

: _______________________________________

9.

Duration/Length of Service

: _______________________________________

10. ESM Identity Card No & Date

: _____________________dated _____________

11. ESM / Ex-Coast Guard died on (if applicable): _______________________________________


12. Cause of Death & whether Attributable to
Military / Coast Guard Service

: _______________________________________

13. Particulars of Dependent Children:Ser


No
1.
2.
3.
4.
5.
6.

Name

Gender

Date of Birth

It is certified that the above information is checked from the Discharge Book of
Ex-Servicemen / Ex-Coast Guard and found to be correct.
Office Seal:
Date: ________________
Place: _______________

(Signature of Dir RSB/ZSB/Coast Guard Headquarter)


(Rubber Stamp of Signing Officer)

5
Annexure-2

CERTIFICATE FOR PM SCHOLARSHIP

1.

It is certified that Ms. / Mr._____________________ is Bonafide student of

__________________________________ College / Institute. His / Her roll number is


__________ and he / she is studying in the 1st

/ 2nd

/ 3rd

/ 4th / 5th

year of

_______________ (Name of Course) in ____________________ branch (if any). He / she


has joined this College / Institute in the academic year _______________ and the course will
be completed in the month of ____________ 20____.
2.

This is also certified that _____________ (Name of Course) is a Professional Degree

Course and this College / Institute is approved by _________________________________.


3.

This is also certified that student is getting Rs._____________ per month / year (If not

getting write N/A) scholarship / stipend from this College / Institute or from any other sources.

College Seal

Date

Signature of Principal / Dean / Registrar


(Rubber Stamp of signing authority will be affixed)

______________

Place ______________

Note- Failure to attach Bonafide Certificate as per this specimen will lead to rejection
of application. Any amendment / left blank / use of whitener will not be accepted.

Você também pode gostar