Escolar Documentos
Profissional Documentos
Cultura Documentos
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 : ________________
2
Selection Serial Number
(To be allotted by KSB) ......................
APPLICATION FOR PRIME MINISTERS SCHOLARSHIP - 2014-15
Recent
Photograph
of Student
1.
________________________________________
2.
Gender (tick)
Male / Female
3.
Date of Birth
4.
4.
________________________________________
(Correspondence Address)
________________________________________
________________________________________
-
Married / Unmarried
________________________________________
5.
E-mail ID of Student
________________________________________
6.
Contact No of Student
________________________________________
7.
8.
9.
10.
(a)
- ________________________________________
(b)
Service No __________________
(d)
(c)
Rank ____________________
______________________________________
(b)
(a)
(b)
11.
___________________________________________
12.
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.
Date __________________
__________________________________________________________________________
FOR OFFICIAL (KENDRIYA SAINIK BOARD) USE ONLY
Remarks & Signature of Checking Clerk
_______________________________
_______________________________
_______________________________
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.
: _______________________________________
5.
Trade
: _______________________________________
6.
Date of Enrolment
: _______________________________________
7.
Date of Discharge
: _______________________________________
8.
: _______________________________________
9.
Duration/Length of Service
: _______________________________________
: _____________________dated _____________
: _______________________________________
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: _______________
5
Annexure-2
1.
/ 2nd
/ 3rd
/ 4th / 5th
year of
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
______________
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.