APPLICATION FORM FOR SCHOLARSHIP

(For Hon’ble Chief Minister Relief Fund)

To,
The Hon’ble Chief Minister,
Government of West Bengal,
Nabanna, Photograph
325, Sarat Chatterjee Road,
Howrah-711102

Personal Details
1. Name :

2. Guardian’s Name :
3. Date of Birth : / / 4. Religion :

5. Gender : 6. Sub-Caste :

Contact Details
7. Permanent Address:

8. District : 9. PIN :

10. Mobile No : 11. Email :

Academic Details

Name of Exam Board / University Year of Passing Grade % of Marks

Current Course Details

12. Course Name :

13. Course Duration : 14. Season :

15. Name of the Institution :

16. Address of the Institution :

Bank Details
17. Account Number : 18. IFSC Code :

19. Bank Name : 20. Branch Name :

I hereby declare that all the above information are correct & true to the best of my knowledge and behalf.

Place :

Date : / / Signature of the Applicant

 SELF DECLARATION (1st TIME)

I am , Son of/Daughter of
. My current address is
, District and
PIN Code , do here by declare that I have been reading in Class

. My current academic session is 2021-2022 at

(School/College University Name & Address) and I

have not received any kind of Scholarships or Financial assistance for my current course from any
Government Department or any Private Agencies during this year.

Signature of the Applicant

Counter Singed by the Head of the Institute with Seal

 RECOMENDATION FROM M.L.A.

To Whom It may Concern

I am , son of/daughter of
, a permanent resident at
, Post ,
Police Station , District ,
PIN in the State of West Bengal. My monthly family income is,
₹ .

Signature of the Applicant

Counter Singed by the M.L.A with Seal