Blank formats for Rayagada Block SSEPD Section.

1. ANNEXuRE -I
fippLicaTION FORM
(BANISHREE-ASchemedofScho]arshipforPhysica]]yCha]]engedStudent)
(To be filled by the Candidates)
For the year.................................
1, Name in Full
(In Block Letter) ...................................................................... „ ................... „ ........................
2. Address ........................ „ ........................... „ ...............,........ „...„ ..............-.............................
VI«a§e/Vvard.....................................................P.S.................................„.„..........................
G.P........................................"...............................-.........................................-...................
BIockINAC"unicipality..................................„........................„.............„......„.....................
District.........................................................:...................-............................-.....................
3. Category of Disabjljty
(Pl. Tick whichever is applicable)(V)
4. Are you a citizen of India ? (Pl. Tick) (/)
5. Whether Scheduled Caste / Tribe / OBC / General
(please mention)
6. Male / Female (please mention)
7. Date of Birth (Please mention)
OH / HH / VH / MR / CP
Yes / No
8.NameandAddressoftheFather/MothertGuardian..........................................................
•........-.................................................................-.......-.......-.-.....,..........`..".'...".....p.....-'
•..........................................................................................................'.................I.........I.......
9. (a) Relationship with the Guardian (if applicable)
(a) Total monthly income of the Parents / Guardian
10. Nature of Scholarship (Please Tick) (V/)
11. (a) Have you ever received Scholarshjp under any other :
Scheme, (Please Tick) (V)
(Fresh / Renewal}
Yes / No

2. J/ i' `,cS "iJ:.c,.I->
t. .`-.:z..`:, ;n `/hich you received the Scholarship
(:I,` ->.3i:ic! far which you received such scholarship :
12. Mention
(a) Class for which I am applying for Scholarship
(b) Academic year of such class
© Date on which you got admission
€'
13. (a) lfyou arevisually challenged student, indicate if you : Yes/Nc
have engaged a reader ? (Please Tick)(`/)
i`'>`, lf you are Orthopaedically Handicapped students :
!~,`:;i`g 75% and above disability indicate the mode of
trar.si:ort.
14. Documents Attached :
(I) Income certificate/copyofBPLcard (PI. lick)(/) : Yes/ No
(ii) D4sability certificate (Pl. Tick) (/) Yes / No
(iii) Mark-sheet of last Exam. Passed (PI. lick) (`/) Yes / No
CtvJ @artyt` Wc_ No tt;e¥oi
I declare that I have not received (not receiving) an}p' Other financial assistance
from State / Central Govt.
Signati.I-;3 :`.r trc. Student
Da?£ ,
Pla'=e :

3. (To be filled by Head of School / Colleges / Educational Institutions)
I Certify that :
* The information furnished b; the candidates (name ........................ „.`..... „ ...................... „
.......,................................................. ) have been verified and found correct
* The School / Institutions in. which the candidate is studying is
Govemmenvrecognised private schoomnstitutions (Pl. Tick){^:~;I `^t which ever is applicable
* The application is recommended.
Signature of the Head of the Schcol /Institution
Name........................................................I-......
(ln Block letter)
Address......................„.................„...................
..............................-........................-.....,,,,,,,......
•.................................................................,........
•...........................I.....................................,,,,,....
Date................................Place..........................
( To be filled in by Sanctioning Authority )
I have verified the jnformations as furnished by head of School / Institution. I hereby santion
Rs .................................... towards Scholarship and Rs ................................................. towards
Reader's allowance/mobility support, thus totaling to Rs ..........................................................
Sanction Order No ..................... „ .............. Date ......................................
Signature with Seal of
B.D.O./Sub-Col(ec+.or