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: SSP2021S50603470303 Application Date: 27-08-2021
BASIC INFORMATION
Student's Name: CHAMELI KHATUN Father's Name: ASRAFUL MONDAL
Date of Birth: 02-06-2005 Mother's Name: ANARKOLI BEGUM
Gender: Female Annual Family Income: 48000
Marital Status: Unmarried Guardian's / Husband's Name: ASRAFUL MONDAL
E-mail Id: chameli45@gmail.com Religion: Muslim
Mobile No: 9593294122
ADDRESS INFORMATION
Permanent Address Present Address
Domicile State: WEST BENGAL State: WEST BENGAL
Domicile District: MURSHIDABAD District:MURSHIDABAD
Block/Municipality:Hariharpara(BLOCK) Block/ Municipality:Hariharpara(BLOCK)
Permanent Address: RAJNAGAR Present Address: RAJNAGAR
Post Office: RAJNAGAR Post Office: RAJNAGAR
Police Station: HARIHARPARA Police Station: HARIHARPARA
Pin: 742175 Pin: 742175

ACADEMIC INFORMATION
Previous Academic Information Present Academic Information
Previous Institute Name: GOBINDAPUR Institution District :MURSHIDABAD
RAJNAGAR HIGH Institution Name: GOBINDAPUR RAJNAGAR HIGH
Previous Class / Course Name: X Current Class / Course Name : XI
Previous Year of Study: X Current year of Study :XI
Name of the Board of Are you a Hosteller: No
last Exam Passed: West Bengal council of Higher Name of the Board / Council / University : West Bengal council of
Secondary Education Higher Secondary Education
Year of Passing Last Exam: 2021 Course Duration : 1 Year
% of Marks Obtained
in Last Examination: 61.57
BANK ACCOUNT DETAILS
Name as per Bank Passbook:CHAMELI KHATUN
IFSC: IOBA0003486
Savings bank account no.: XXXXXXX6555
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.48000 . 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 CHAMELI 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.

1/1

Powered by TCPDF (www.tcpdf.org)