Government of Andhra Pradesh

Department of Backward Classes (EBC)

Application for Post-Matric Scholarship - Fresh 2010-11

lication No: 2010 0268 3093 2. Application Date: 03-12-2010 3. Caste / Sub Caste: E-BC(listed) / T

ge Details :
ege Name & nature: ST ANNS ENGINEERING COLLEGE CHIRALA SACE , Private College

ege District &

Prakasam & Chirala 6. University/Board : JNT UNIVERSITY KAKINADA 7. CET / Non CET : 2706091 67785
al:
rse Name 9. College
e Year BTECH (CSE) / I Yr / 4Yrs  Admission No / 10NC1A05B3 / 12-10-2010    
on of Course Admission Date:
ent Details :
11. Father / Mother
udent Name : VADDE ADI SESHU VADDE SAMBAIAH 12. Sex : Male
Name :
14. Income
Certificate Details
test Family
(Number, Date,
l Income (in 96000.0 15. Ration Card : PAP0882018000
District, Mandal,
Name & employee
code of MRO):
ent SSC Details :
SC or 0500278, / Regular 17. Year of Pass : 2008 18. Date of Birth: 13-06-1993
alent HT
er / SSC Pass
el / Scholarship Type Details :
20. Distance from 21. Department
holarship
Student Managed Hostel College to place of 10.0 Attached Hostel -
Residence in Kms : Name :
ent Bank Account Details :
nk Name : 23. Bank A/c No : 36602210045472 24. Status :
ess for Communication :
26. Mandal &
dress : 10-9-1 Chirala & Perala 27. District & PIN : Prakasam
Village :
Mail : saec10.5b3@rediffmail.com 29. Mobile Number : 9394133156 30. UID(Aadhar)No. :
r Details:
her category 32. Field Officer 32. District Officer DC(EBC)
ASWO EBC Office,CHIRALA
Address : Address : Office,Ongole

Year Sanction / Release Particulars :

Sanctioned RTF:0,Released Sanctioned MTF :0,Release 35. MTF amount
TF Details : 34. MTF Details :
RTF:0 MTF0 Received Y/N :
ficated Enclosed :
 Caste
Certific
from
Compe
Author
come  Photo c
38. Bonafide from 39. Any other
cate from Yes Yes of Ratio
College Principal : Certificate :
Card.
 SSC
Certific
 Transfe
Certific

Declaration by the Student and Parent

The information given above is correct
I am not availing any other scholarship for this purpose from any other sources
I shall abide by the terms and conditions for sanction of scholarship
If any discrepancies found in the above data, I shall be liable for the action taken by the department

 
ature of the Student           Signature of the Father / Mother / Guardian

Verification Report of College Principal

is to certify that the information furnished above is verified with the records and found to be correct. He / She is a bonafide student of our college studying
H (CSE) / I Yr  (Course & Course Year) during 2010-11.
 
Signature of the Principal
e:
(With College Seal)           

Verification Report of A.S.W.O

have verified the contents of the application with reference to the college records and original certificates, physically identified the student and certify the fo
:
   
C/Other equivalent exams.Registration No. : Correct / Incorrect.

ste / Sub Caste (Group) : Correct / Incorrect.

sent Course of study & Year & Admission Number : Correct / Incorrect.

al family income from all sources as per latest income certificate

: Correct / Incorrect.
ained after 15-9-2010

otograph Scanned image. : Correct / Incorrect.

ion Card Details. : Correct / Incorrect.

commend for sanction of Post-matric Scholarship under DS SMH CAH DAH

o not recommend the sanction of scholarship for the following reasons. (Please specify)

ave physically verified the SSC Certificate in person

e: Signature (A.S.W.O) of the Field Officer with seal