Government of West Bengal

Office of the PO cum DWO, ALIPURDUAR District

APPLICATION FOR PRE MATRIC SCHOLARSHIP TO SC/ST / OBC STUDENTS (AY: 2022-23)
NEW/RENEWAL Application Serial No. : WB020121317404

1. Full Name of Applicant Shri/Kumari : ANKIT ORAON

2. Father's/Husband's Name : LATE FRANCIS ORAON.
4. Date of
3. Gender : Male : 2005-11-24
Birth
5. Nationality : INDIAN
7. Telephone
6. Aadhar No : 493049406659 : 7365850431
No.

8. a) Caste : ST b) Sub-Caste : ORAON

c) Caste Certificate No : WB2001ST201705161 d) Dated : 2017-12-07
e) Issuing Authority,
: SDO Alipurduar, ALIPURDUAR District
District
f) Khadyasathi No : AAY0205481175
9. a)State to which applicant actually belongs : West Bengal
b) Permanent Address : SUBHASINI TEA ESTATE, P.O- HASIMARA
P.O. P.S. District PIN
HASIMARA JAIGAON ALIPURDUAR 735215
c) Present Address : SUBHASINI TEA ESTATE, P.O- HASIMARA
P.O. P.S. District PIN
HASIMARA JAIGAON ALIPURDUAR 735215
d) Whether in full time employment : No
10. Particulars regarding MOTHER who supports in applicant’s studies
a) Name : HEMANTI ORAON
b) Occupation (if employed, give income certificate from the
: TG WORKER
Employer)
c) Address : SUBHASINI TEA ESTATE, P.O- HASIMARA
11.Bank Details::
Bank Name Branch Savings A/C No. IFSC Code Address
State Bank of India DISTJALPAIGURI
HASIMARA 36621636761 SBIN0001447 WEST BENGAL
735215

12. a) Name of Institution (mentioning State / UT):DEMDIMA FATIMA HIGH SCHOOL

Course Type:-
c)Actual date of joining the d)Tentative date of end of
d)Class of Study
class(Academic year 22-23 only) session(Academic year 22-23 only)
X(X) 2022-01-11 2023-01-10

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 Government of West Bengal
Office of the PO cum DWO, ALIPURDUAR District
13.Annual Gross Income (parents / guardians) from all sources : Rs. 48000/-
14.Whether applied for Merit/National Loan Scholarship or any other Stipend / Scholarship : No
15.Whether you in recipient of this scholarship in the previous year : NO

Hostel Details
Name & Address of Hostel Date of joining in current Session Charge payable
Dimdima Fatima H. School 2022-01-11 11000
**For academic session 22-23 only**

(A certificate by Hostel Superintendent and duly countersigned by the Head of the Institution showing exact date of admission to
Hostel & charge payable to be submitted)
17.Identification Proof:Aadhaar Card No. XXXXXXXX6659
I agree to seed my aadhaar details with my bank account.
I undertake that all the statements given above are correct and I shall be liable to penal action if any statement made above is found
false/incorrect.
I hereby declare that I have not applied for any other scholarship/stipend, etc. from any other government sources.

Place ------------------------------
Signature of the Applicant
Date ------------------------------

E
CERTIFICATE OF INSTITUTION

U T N
The statements made by the applicant in Sl. No. 11,12,14,15,16 are correct to the best of my knowledge. This Institute is affiliated

T
T I T O
to the ______________________________________ University / Board & is recognized by the Government of India / State

I
Government of _________________________________. Minimum qualification for admission to the course is a pass in

S
IN IFICA
____________________ Examination.
Certify that,the applicant has not applied for any other scholarship and account number is correct and registered with this applicant
as per bank passbook.

V ER E
SEAL
L B I N E
_____________________________________

W IL N L
Signature of Head of
Institution

E O
Name (in Block Letter) :
Designation :

D O N Address :
State :
Pin Code :
Affiliation/Registration No.

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 Government of West Bengal
Office of the PO cum DWO, ALIPURDUAR District

RESIDENTIAL CERTIFICATE

(Should be signed either by a Member of Parliament or Member of a State Legislature, or a Municipal Commissioner / Councillor /
Member of Zilla Parishad / Member,GTA / Savapati of Panchayat Samity or a Government Officer. The issuing authority is
requested to observe due caution as Scholarship is awarded on the basis of this very important Document.)
Certified that the information furnished at point nos. 1 to 11 and 13 overleaf are correct to the best of my knowledge.
Place ------------------------------

Date ------------------------------

SEAL Name (in Block

Letter) :
Designation :
Address :
State :
Pin Code :

DECLARATION OF INCOME

(To be given by the parents/ guardians when the candidate is not employed)
Certified that the gross annual income from all sources in respect of my family is Rs.____________ (Rupees
_______________________________Only) one / two / three of my sons is / are availing such scholarships. I make myself
responsible for the accuracy of the fact & figures furnished.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
______________________________ and the Government's decision in this regard shall be final and binding on me.

Place ------------------------------
Signature in full
Date ------------------------------

1. Applicant is to submit the ***computer-generated filled-in application form (duly signed) to the Madarihat - Birpara Block
Development Office. .
2. Documents to be submitted along with computer generated application form:
A. 1(One) Copy recent stamp size coloured photograph of the applicant duly attested and pasted on the application.
B1. An attested copy of the caste certificate/Acknowledgement slip of the applicant(For prematric scholarship).
B2. An attested copy of the caste certificate of the applicant(For postmatric scholarship).
C. An attested copy of the marksheet/certificate of the last examination passed
D. Copy of the first page of bank passbook(where the account number and bank details is mentioned).
E. Copy of Identification Proof (Aadhaar Card).
F. Income certificate and proof of Date of Birth(Birth Certificate / Madhyamik Admit Card).
G. Copy of Khadyasathi card .
3. The required certificates on the body of the application form are to be provided by the concerned authorities /persons.
4. The application form has to be submitted by 31/10/2022.

Application Date:-2022-09-27

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