GOVERNMENT OF ANDHRA PRADESH

MINORITIES WELFARE DEPARTMENT

APPLICATION FOR PRE MATRIC SCHOLARSHIP FOR MINORITIES

FOR THE ACADEMIC YEAR 20___ TO 20___

Renewal /Fresh

Registration No.: Unique. ID No:

_________________

1.Name of the student:

2.Father’s/Guardian’s Name:

3.Community:Muslim Christian Sikh Buddhist Parsi

4.Sex : Male Female

Date Month Year

5.Date of Birth :
(as per School Record)

6.Permanent Address: ________________________________

House No. _______________ Locality ______________

Village/Ward ______________ Mandal/Municipality/____________

Town/City
Constituency_____________ District _________________

Pincode _______________ State _________________

Phone No:_________

7.Present Address: ________________________________

House No ________________ Locality ______________

Village/Ward _______________ Mandal/Municipality ____________

Town/City

Constituency_____________ District ____________________

Pincode ______________ State _________________

Phone No._____________

8. Physically Challenged: Yes No

9. i) Total Annual income of Parents/ Guardian:____________________

ii) Ration Card Type White Pink

10. Received any Scholarship amount (previous year): Yes/No ______

If Yes furnish Uniq Id. No. __________________________

11. Details of present Class of Study

a) Name of the Class:______________ b)Admission No: __________

c) Medium of Course : English Telugu
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12. Name of the School: ___________________________________________

a) Address: ______________________b) Village/Ward _______________

c) Mandal/Municipality/_________________ d) Constituency _________________

Town/City
e) District _________________ f) Phone No: ________________________

13. Status of School: a) Government b) Government Aided :

c) Private (Recognized)

14. Previous Examination Passed (Class)

a) Total Marks Obtained b) Percentage of Marks

15. Total Annual Course Fee ______________

a) Admission Fee b) Tuition Fee

16. Details of Student’s bank Account

a) Name of the Student (as in the Bank Account)

b) Name of the Bank
c) Bank Branch (full address)___________________________
State__________ District_____________Pin____________
d) Branch Code No._______________
e) Bank Account No._________________
(In words________________________________________)
f) Type of Bank Account_________________ Saving/Current
g) MICR code of the Bank__________________

h) Mode of Electronic transfer available in the Bank_____________

IFSC/ECA/RTGS/NEFT/CBS/Code Number (if any)
Declaration of the Student

I hereby affirm that the above details entered in the application

submitted through online are correct & true and that I will be liable for
prosecution if any information furnished above is found incorrect/False.

Signature of the Applicant. Signature of the Parent.

Date:
Income Certificate
(To be certified by Tahasildar)
This is to certify that Master / Kum. ______________________________
S/o. D/o _____________________________ Resident of __________________
Village ___________________ Mandal ________________________District.
His/Her Parent /Guardian’s Name Sri___________________________ income is
Rs. ___________________ per annum and belongs to __________ Community.

Place: Signature of Tahasildar

Date: (With Seal)
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Study / Bonafide Certificate

Photograph
(To be Certified by the Head Master)
Attested by
Head Master

This is to certify that Master /Kum._____________________

S/O.,D/o. _______________________ Resident of ______________
Village ___________________ Mandal is studying _______________ course in
our School During the Academic Year _______ belongs to _________Community as
per the information of the School Records.

a) Bank Account No. of the School:

b) Name of the Bank & Branch
c) Bank Branch (full address) __________________________
State__________ District_____________Pin____________
d) Branch Code No._______________
e) Bank Account No.________________
(In words________________________________________)
f)Type of Bank Account_________________ Saving/Current

g) MICR code of the Bank__________________

h) Mode of Electronic transfer available in the Bank_____________

IFSC/ECA/RTGS/NEFT/CBS/Code Number (if any)

Reorganization No. Signature of Head Master

Date: (With Institution Seal)

Verification Report

I have verified the contents of the application and also the School Records and
found that the certification made by the Head master concerned is correct to the
best of my knowledge.

Mandal Education Officer/

Dy. Inspector of School

Note: For details of scholarship eligibility please see in our Web site:“ www.apsmfc.com”

Enclosures:
1) Income Certificate issued by Tahasildar
2) Bonafide Certificate
3) Xerox Copy of Bank pass book in the name of Student
4) Xerox copy of Previous year marks certificate(Progress report)
5) Receipt of the Annual course fee.
6) Date of Birth proof certificate (as per school record)