“ȪŠ\‚š]”€Ȫ€Ȫ_ ˜è™ȡ¡ȰȪ]”\”“ȯǔ‡›ȯ€ȯ€ȡ™ȡ[›™€›ȯȊšǔ‡›ȡBHOPAL €ȯ ͪ”†°ȡ‚[€ã™ȡŽ

˜Ʌ Ȳ”€[€š €ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2018-19
Applicant Unique ID : 2925656
Scheme : Post Metric Scholarship for OBC
Application ID: 4110041
Version No: 1 Verification Code: 3124 Lock Date: 27/12/2018 IPAddress : 43.229.95.39
Instructions for colleges & offices: Please check all information in each section and place a tick mark in on the box. Institute will use the first Box
with I sign and Sanctioning Office will use second box with O sign in it.
1. Personal Details SAMAGRA ID : 161368272 Aadhaar No : XXXXXXXX2032 Voter ID : --
Name : VIPIN SINGH As per SAMAGRA: Vipin Singh AS Per Board Marksheet : VIPIN SINGH
Gender : Male Religion : Hindu Special Category : No
Father's Name : AMAR AS Per Board Marksheet : AMAR SINGH
Mother's Name : SHIVKUMARI AS Per Board Marksheet : SHIVKUMARI SINGH
I O
Date of Birth : 21/08/1999 AS Per Board Marksheet : 21/08/1999

2.Category OBC AS Per Board Marksheet : OBC

Caste Certificate : No: 51169 by :Tehsil Office Sirmour On :27/08/2009 I O
3.Academic Details Admission Date : 18/07/2018 Enrollment No. : 0537EC171009 I O
University/Board Name : Rajiv Gandhi Technical University, Bhopal
Institute : 20372-Sagar Institute of Science Technology and Research, (SISTec-R), Bhopal District: BHOPAL
Course : 3021/B E [Full Time]/Electronics and Communication Engineering/2nd Year
Hostel Status: Day Scholar

4. 10th Board Details 10th Board Name: MP Board of Secondary Education, Year: 2013-14, Roll No.: 143115199

School Scholarship Details Generated From Samagra Portal

Name : VIPIN SINGH Category : Gen DOB : XXXXXX1999 Gender : Male
Father Name : AMAR SINGH BPL : “¡ȣȲ CWSN : No

Sno Academic Year School Current Class

1 2015-16 MAA SARASWATI GYAN MANDIR HIGHER SECONDARY 12 th
SCHOOL
2 2014-15 MAA SARASWATI GYAN MANDIR HIGHER SECONDARY 11 th
SCHOOL

5. Last Year Exam Details : Exam Name: 3021/B E [Full Time]/Electronics and Communication Engineering/1st Year, I O
Exam Date : 26/10/2018
School./Institute :Sagar Institute of Science Technology and Research, (SISTec-R), Bhopal Result : Promoted to next higher Course Year
(Pass/ATKT)
6. Total Annual Family Income : Rs.40000/-
Income Certificate issued by-Revenue Department On : 06/10/2017
7 Contact Details Mobile No : 8959689363 VIPINSINGH8959[AT]GMAIL[DOT]COM I O
Correspondance Address : WARD NO 18 NEAR KHER MAI MANDIR HANUMAN NAGAR RAGHURAJ NAGAR, District :- SATNA

Permanent Address : WARD NO 18 NEAR KHER MAI MANDIR HANUMAN NAGAR RAGHURAJ NAGAR, District :- SATNA
8. Bank Account No: 1305001500139620, IFS Code: PUNB0130500, PUNJAB NATIONAL BANK, BHOPAL, HABIB I O
GANJ, BHOPAL
9. Previous Year Sanction Order Details Application ID : 3229274
I O
Sanction Order No.: 1163722, Sanction Order Date: 04/05/2018, Sanction Amount: Rs.27470/-

Generated by Scholarship Portal as on 27/12/2018

“ȪŠ\‚š]”€Ȫ€Ȫ_ ˜è™ȡ¡ȰȪ]”\”“ȯǔ‡›ȯ€ȯ€ȡ™ȡ[›™€›ȯȊšǔ‡›ȡBHOPAL €ȯ ͪ”†°ȡ‚[€ã™ȡŽ
˜Ʌ Ȳ”€[€š €ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2018-19
Applicant Unique ID : 2925656
Scheme : Post Metric Scholarship for OBC
Application ID: 4110041
Version No: 1 Verification Code: 3124 Lock Date: 27/12/2018 IPAddress : 43.229.95.39
]ȯ‘€fȲ”ȡ›€€ȧƒȪŸŽȡDeclaration from Student and his Parent
˜ɇVIPIN SINGH s/w/o AMAR ƒȪŸŽȡ€šȡ€šȢ¡Ǘȱͩ€†ȡğǙǓ“Ȣ“Ȣ€šŽ€ȧh“›ȡ^“]ȯ‘“•Ȩ˜[˜ȯ—šȣ‚_ —Ȣ‡ȡ“€ȡǐš™ɉ
ǔ‡ ˜ȯ˜ǕəǾ” ȯ˜ȯšȡ“ȡ˜˜ȡȡͪ”ȡ€ȡ“ȡ˜10th Board €ȧ‡ȡ“€ȡšȣ€ȯ\“Ǖ ȡš‚[‡ǓĤ˜ȡŽ”ğ€ȯ\“Ǖ ȡšͧ›Ȳ‚]’ȡš“Ȳ
‚Ÿ[€ȡ”šȣ¢ȡ”ǐšŽȡ˜]™ Ȳ–Ȳ’Ȣ‡ȡ“€ȡšȣ]™Ĥ˜ȡŽ”ğ€ȯ\“Ǖ ȡš[˜ȡ“˜ȯ\ڙ™“š€Ȫ [€Ȫ [€ȡŸ[–ɇ€ȡȯĤȯž€ȡ
Ĥ€ȡšfȲ Ȳèȡ Ȳ–Ȳ’Ȣ‡ȡ“€ȡšȣ ¡ȣfȲ ×™¡ȰfȲ”ȪŠ[›”š‘èȡȯ«€ȯǾ”˜ȯ\”›ȪŒ€ȧ‚_¡Ȱ)˜ɇ[˜ȡ“žȰ¢ͨŽ€ ğ˜ȯ€ȯ›f€
¡ȣĤ€ȡš€ȧè€Ȩ›ͧž[”€ȯͧ›f]ȯ‘“ͩ€™ȡ¡Ǘȱ)™Ǒ‘^“˜ȯ ȯ€Ȫ_—Ȣ‡ȡ“€ȡšȣ\ ×™™ȡğǕǑŠ”ǗŽ[”ȡ_‡ȡȢ¡ȰȪ˜ȯšȡ†ȡğǙǓ]ȯ‘“•ȡ˜[
 ȲèȡèȢ€ǙǓ€ȡ[\ͬ’€ȡšȣͪ—ȡ‚ƮȡšȡǓ“šèͩ€f‡ȡ“ȯ”š˜ɇ蝙‡–ȡ–‘ȡšš¡Ǘȱ‚ȡš¡Ǘȱ‚Ȣ)žȡ “˜ȯšȯͪǽƨ¤ȡ“Ǘ“Ȣ€ȡ™[ȡ¡ȣ€š“ȯ€ȯ
ͧ›f蝏Ȳğ¡Ȫ‚ȡ)
˜ɇ€Ȫ [”ǗŽ[¡Ȫ“ȯ€ȯ”¡›ȯ€Ȫ [ Ȳèȡ†Ȫ°‘ȯȡ‘ȯȢ¡ǗȱȪ™¡˜ȯšȣ”ǗŽ[ǔ‡à˜ȯ‘ȡšȣ¡Ȫ‚Ȣͩ€˜ȯšȯƮȡšȡ”Ǘ[˜Ʌ Ȳ–Ȳͬ’€Ȫ [€ȯͧ›™ȯĤȡƯ
†ȡğǙͪƣžȡ “€Ȫ Ȳ–Ȳͬ’ǔ‡›ȡ€ȡ™ȡ[›™€ȯ˜ȡڙ˜ ȯ…ȡ›ȡ“ ȯȡ” €š‘ǗȲ‚ȡ‘ǗȲ‚Ȣ)†ȡğǙͪƣȡ” “€š“ȯͩ€ǔèǓ˜Ʌžȡ “˜ȯšȯ
ͪǾƨ€Ȫ_—Ȣ€ȡ™ȡ[ȡ¡ȣ€š“ȯ€ȯͧ›™ȯ蝏Ȳğš¡ȯ‚ȡ)

(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

Declaration from Institute Head & Institute Scholarship Nodal Officer

We, hereby, certify that student is enrolled in college in the course approved/recognized by concerned board/council/university. All details filled
by student in above application form have been verified with original documents & have been found to be correct / authentic. Applicant has
promoted to next higher course year(Pass/ATKT). College has ORIGINAL COPY of his Transfer Certificate. Applicant is not enrolled in another
institute. Applicant's attendance is regular.
We have verified all details as per scheme guidlelines & instructions and recommend him for sanction of scholarship as per the rules. We also
undertake that, if the above student does not attend the classes regularly or discontinues the course, We will immediately report it on portal and
to concerned district office so that his scholarship can be put on hold. In case any information of found to be incorrect, Government will be free to
initiate legal and penal action against the institute.

(Signature ) (Signature ) Date (Signature )

Scholarship Nodal Officer HOD Director/Prinicpal

Income Certificate Details

Generated by Scholarship Portal as on 27/12/2018

“ȪŠ\‚š]”€Ȫ€Ȫ_ ˜è™ȡ¡ȰȪ]”\”“ȯǔ‡›ȯ€ȯ€ȡ™ȡ[›™€›ȯȊšǔ‡›ȡBHOPAL €ȯ ͪ”†°ȡ‚[€ã™ȡŽ
˜Ʌ Ȳ”€[€š €ȯ¡Ȱ)

Renewal Application Backward Classes & Minorities Welfare Dept.

Madhya PradeshScholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2018-19
Applicant Unique ID : 2925656
Scheme : Post Metric Scholarship for OBC
Application ID: 4110041
Version No: 1 Verification Code: 3124 Lock Date: 27/12/2018 IPAddress : 43.229.95.39

Previous Year MarkSheet

Fees Receipt/ Admission Slip

(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

“ȪŠ†ȡğ†ȡğȡ€ȯ]ȯ‘“•Ȩ˜[”š™Ǒ‘€¢ȡȢ€ȡͪšŽ`”›Þ’“¡ȣȲ¡Ȫ“ȯ”š ȲèȡĤ˜Ǖ†ȡğ†ȡğȡ€ȯȢ€ȧ˜Ǘ›ĤǓ
˜ȡ€[žȢŠ ȯ
‡ȡ“€ȡšȣ ×™ȡͪ”€šȯ)
™Ǒ‘]”‚›Ø™ɉ€ȯ]’ȡš”š†ȡğǙǓ›ȯȯ¡Ǖ]”ȡf‚™ȯȪ]”€ȧ†ȡğǙͪƣǓ“šè€š‘ȣ‡ȡȯ‚Ȣȡ†ȡğǙͪƣ€ȧǔ‡“Ȣš€˜‘ȣ‚_¡Ȱ` ȯ
ȡ” ›ȯ›ȣ‡ȡȯ‚Ȣ)^ š¡€ȯͩЙȡ€›ȡ” ȯ ˜ǔےͪ’ȡȸ€Ȫ¡˜ȯžȡ€ȯͧ›fͩ€ Ȣ—Ȣ™Ȫ‡“ȡ€ȯ\ۏ‚[ͩ€ Ȣ—Ȣ†ȡğǙͪƣ ȯͪǔ‡[(Debarred)
€šǑ‘™ȡ‡ȡ™ȯ‚ȡȡͪ’ȡȸ€Ȫ€ȡ›ȣ Ǘ…Ȣ(Black List) ˜ɅŒȡ›Ǒ‘™ȡ‡ȡ™ȯ‚ȡȡ†ȡğǙͪƣèȢ€Ǚ€ȡ[\ͬ’€ȡšȣ\ȡ\ۙ ¢˜\ͬ’€ȡšȣ]æ™€
 ˜ˆȯ‚ɅȪ` €ȯͪǽڑ—ȡšȢ™‘ÖŒ ȲǑ¡ȡ€ȧ’ȡšȡjȲfȲ€ȯ¡f•]_]š‘‡[€šȡ_‡ȡ€š É€ȡ™[ȡ¡ȣ€ȧ
‡ȡȯ‚Ȣ)

Generated by Scholarship Portal as on 27/12/2018