West Bengal Minorities' Development and Finance Corporation

A statutory Corporation under Minority Affairs & Madrasha Education Department,

Government of West Bengal
"Amber", DD/27E,Salt Lake City Sector-I, Kolkata-700064, Toll free No:-18001202130

APPLICATION FOR WB PRE MATRIC SCHOLARSHIP 2020-21

Application ID: SSP2020010401233850 Application Date: 19-10-2020
BASIC INFORMATION
Student's Name: REJUAN NAIYA Father's Name: RUHUL AMIN NAIYA
Date of Birth: 24-07-2009 Mother's Name: SABINA BIBI
Gender: Male Annual Family Income: 60000
Marital Status: Unmarried Guardian's / Husband's Name: RUHUL AMIN NAIYA
E-mail Id: Religion: Muslim
Mobile No: 8653200875

ADDRESS INFORMATION
Permanent Address Present Address
Domicile State: WEST BENGAL State: WEST BENGAL
Domicile District: SOUTH 24 PARGANAS District:SOUTH 24 PARGANAS
Block/Municipality:Kulpi Block/ Municipality:Kulpi
Permanent Address: BARA CHUNFULI Present Address: BARA CHUNFULI
Post Office: DAKSHIN JAGADISHPUR Post Office: DAKSHIN JAGADISHPUR
Police Station: DHOLAHAT Police Station: DHOLAHAT
Pin: 743399 Pin: 743399

ACADEMIC INFORMATION
Previous Academic Information Present Academic Information
Previous Institute Name: BARA CHUNFULI FP Institution Name: HARINDANGA KUMUDINI HIGH SCHOOL(HS)
Previous Class / Course Name: IV Current Class / Course Name : V
Previous Year of Study: IV Current year of Study :V
Name of the Board of Are you a Hosteller: No
last Exam Passed: WEST BENGAL BOARD OF Name of the Board / Council / University : West Bengal Board of
PRIMARY EDUCATION Secondary Education
Year of Passing Last Exam: 2019 Course Duration : 1 Year
% of Marks Obtained
in Last Examination: 94.50
BANK ACCOUNT DETAILS
Bank:UNITED BANK OF INDIA
Branch:KULPI
IFSC: UTBI0KPIC29
Savings bank account no.: 0785010834247

Declaration:I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief.

___________________
Signature of Student
DECLARATION OF INCOME
(To be given by the parents/ guardians)

Certified that the gross annual income from all sources in respect of my family is Rs.60000 . I further undertake that in the
event of the particulars given in the declaration being found false, I shall refund the whole amount of the Scholarship paid to
the said Scholarship holder REJUAN NAIYA and the Government's decision in this regard shall be final and binding on me.

__________________________
Signature of the parents/ guardian

Instruction
Student is to submit this ***computer-generated filled-in application form (duly signed) to the
educational institution along with following supporting document:
1. Photocopy of the bank-passbook where the details of bank a/c number,IFSC are mentioned
clearly.

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