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

FRESH
APPLICATION FOR WB SVMCM SCHOLARSHIP 2021-22
Application ID: SSP2021050603338936 Application Date: 09-11-2021
BASIC INFORMATION
Student's Name: HAKIMA KHATUN Father's Name: MD OSMAN GONI
Date of Birth: 10-09-2003 Mother's Name: MOST MINARA BIBI
Gender: Female Annual Family Income: 60000
Marital Status: Unmarried Guardian's / Husband's Name: MD OSMAN GONI
E-mail Id: 2003hakima@gmail.com Religion: Muslim
Mobile No: 7872186473
ADDRESS INFORMATION
Permanent Address Present Address
Domicile State: WEST BENGAL State: WEST BENGAL
Domicile District: MURSHIDABAD District:MURSHIDABAD
Block/Municipality:Samserganj(BLOCK) Block/ Municipality:Samserganj(BLOCK)
Permanent Address: VILL: PROTAPGANJ Present Address: VILL: PROTAPGANJ
Post Office: KANKURIA Post Office: KANKURIA
Police Station: SAMSERGANJ Police Station: SAMSERGANJ
Pin: 742202 Pin: 742202

ACADEMIC INFORMATION
Previous Academic Information Present Academic Information
Previous Institute Name: SULTANPUR ALIA Institution District :MURSHIDABAD
SENIOR MADRASHAH Institution Name: BELDANGA DARUL H.SR.MADRASHA
Previous Class / Course Name: FAZIL Current Class / Course Name : BACHELOR OF ARTS (B.A)
Previous Year of Study: 1st Year Current year of Study :1st Year
Name of the Board of Are you a Hosteller: No
last Exam Passed: West Bengal Board of Madarsa Name of the Board / Council / University : West Bengal Board of
Education Madarsa Education
Year of Passing Last Exam: 2021 Course Duration : 1 Year
% of Marks Obtained
in Last Examination: 87.66
BANK ACCOUNT DETAILS
Name as per Bank Passbook:HAKIMA KHATTUN
IFSC: CNRB0001687
Savings bank account no.: 1687108027199
Declaration:I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I
have not applied for any other scholarship/stipend, etc. from any other government sources.

___________________
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 HAKIMA KHATUN 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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