1 CHECK LIST OF DOCUMENTS TO BE ATTACHED WITH THE APPLICATION FORM Application Form of PM Scholarship of 2012-13 from Page 01 to 10 only.

No other documents will be accepted other than mentioned in the check list. (a) If student born after discharge then affidavit is to be submitted by ESM / ExCoast Guard. (b) Additional Certificates Additional certificate is to be attached in support of the cat 1-5, as mention in brochure. (c) Attested photocopy of Matriculation or equivalent examination certificate for verification of date of birth. (d) Attested photocopy of mark sheet of MEQ as applicable (e.g. 10 plus 2, Graduation / Diploma). In case the MEQ is Graduation / Diploma, then complete mark sheets are required to be submitted. In case of MBA / MCA / B Ed / LLB applicants attested copy of MEQ i.e Graduation. (e) Bonafide Certificate to be issued by Registrar / Dean / Principal of College / Institution pertaining to course for which scholarship is claimed.

Date: _____________________

____________________________ Full Name & Signature of Candidate

Place: ____________________

_______________________________ Name & Signature of ESM / Ex-coast Guard / Widow . CERTIFICATE FROM RSB / ZSB / DIRECTORATE GENERAL OF COAST GUARD It is certified that PM Scholarship application form for academic year 2012-13 in respect of Mr. / Ms. __________________________________________________________ S/o / D/o Ex -____________________________________________________ has been checked, found correct as per check list provided by KSB and the applicant is eligible to apply as per rules of the scheme.

Office seal: Secretary / Director Place: ________________ Date : ________________ RSB / ZSB / Coast Guard Headquarter

2 Selection Serial Number (To be allotted by KSB) ...................... APPLICATION FOR PRIME MINISTERS SCHOLARSHIP FOR THE YEAR 2012-13 Recent Photograph Of Student
(Write your name & ESM/Ex-Coast Guard/widow particular on reverse)

Note:

1.) 2.) 3.) 4.)

Please read column wise guide lines carefully before filing the application Application Form to be filled in Capital letters except email ID. Checklist must be attached with application duly tick marked. One candidate to submit only one application form for one course.

1.

Name. First Name

Middle Name

Surname

2. 3.

Put a tick mark ().

Male

Female

Date of Birth (please attach proof of age) (i.e : Matriculation Certificate). D D M M Y Y Y Y

4. Your Rajya Sainik Board or Zila Sainik Board (Where ESM is registered and obtained ExServicemen Identity Card).

(Only for ESM)

RSB

ZSB

5.

Full Address. (a) Present Correspondence Address: - (Where you want your letter to be sent in case of selection / rejection) House No.

LEAVE BLANK SPACE BETWEEN WORDS

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Street No. & Name

Tehsil

District

State

Pin Code (b) Permanent Address. House No.

Street No. & Name

Tehsil

District

State

Pin Code 6. Telephone Number. STD Code Land Line No. Mobile No.

E-Mail (mandatory)

LEAVE BLANK SPACE BETWEEN WORDS

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7. Ex-Servicemen / Ex-Coast Guard Category - (Mention category as per Para 7 of the Brochure and attach supporting document duly attested).

8.

Ex-Servicemans / Ex-Coast Guards Particulars.

(a) Name of ex-serviceman / Ex-Coast Guard

(b) Service No. (c) Rank (d) Type of Service (Tick one) Army 9. Air Force Navy Coast Guard

Details of MEQ / Course for qualifying (10+2/equivalent or Diploma / Graduation) (a) Name of Course/MEQ

examination

for

scholarship

(b) Year in which exam passed (c) Total Marks (in words)

(in figure) (d) Marks obtained (in words)

(in figure) (e) % of marks scored (in words) (in figure) 10. Whether the applicant is in receipt of any other financial assistance/scholarship/ fellowship from any Govt. / Private source for the course to which the scholarship applied for. If yes, then state the amount and source (Except Prime Minister Scholarship). Yes No Rs (per month / year)

Name of the Source

LEAVE BLANK SPACE BETWEEN WORDS

5 11.
Name of the Course

12.

Duration of Course in Years and Months

in figure in words

13.

Date of Commencement and Approximate Date of Completion.

D (a) Course commenced on D (b) Course completion date approximately D M M Y Y Y Y D M M Y Y Y Y

14.

Details of College / Institute. Name of Student

Roll No. Name of College

Full Address of College

State Pin Code Tele No. (with STD Code) E-Mail ID (if any)

College Website

LEAVE BLANK SPACE BETWEEN WORDS

6 15. Regulatory Bodies/ Council. (For example all Engineering Degrees and Management Degree Courses are recognized by AICTE & UGC and all Medical Degree are recognized by Medical Council of India or Dental Council of India, specify as per case).

16.

Details of Bank Account of SBI or PNB for Electronic Clearing Services ((PLEASE ATTACH A PHOTOCOPY OF PASS BOOK, ONE CROSSED BLANK CHEQUE LEEF SHOWING YOUR ACCOUNT NUMBER).
Name of account holder:

Name of Bank (Put a tick mark () Branch Name:

SBI

PNB

(PLEASE ATTACH A PHOTOCOPY OF CHEQUE & PASS BOOK)

Account No. REPEAT Account No.

17. Furnish particulars of all children in order of age, as reflected in the Discharge Book or attached an affidavit in case child born after discharge.
Sl. No. Name of Child Gender Date of Birth

18. Details of brother/sister availing / availed the PMs Scholarship, if any. (Including yourself if granted earlier) Sl. No. Selection Serial No. given by KSB Name of the brother/sister Course of Study Academic year in which applied Amount received so far

LEAVE BLANK SPACE BETWEEN WORDS

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19. Declaration. Certified that the particulars given by me in the application are correct and any false statement made by us will disqualify me / my ward for award of PMs Scholarship Scheme, besides recovery of scholarship already paid. I also undertake to abide by the conditions mentioned in the general instructions of the scheme.

Place: Date:

(Signature of ward) _____________________________ (Full Name of Ward) _____________________________

Place: Date:

(Signature of Parent) ____________________________ (Full Name of Parent) ___________________________

__________________________________________________________________________

FOR OFFICIAL (KSB) USE ONLY

Signature of Supervisor/ IC PMSS

Remarks of Supervisor / IC PMSS

___________________________

_______________________________ _______________________________ _______________________________

RECOMMENDED / NOT RECOMMENDED

Signature of JD PMSS

Remarks of JD PMSS

____________________

_______________________________ _______________________________ _______________________________

8 SPECIMEN COPY OF EX-SERVICEMEN / EX-COAST GUARD CERTIFICATE (This is important document, fill it carefully) (In lieu of Discharge Book) 1. 2. 3. 4. 5. 6. 7. 8. 9. Type of
Service (Army, Navy, Air Force or Coast Guard)

: _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________ : _______________________________________

Service No. Rank Name & Initials Trade Date of enrolment Date of Discharge Reason for Discharge Duration/Length of Service

10. Regular / Reserve

11. ESM ID Card issued vide sl no RSB/ZSB/dated... 12. ESM / Ex-coast Guard died on (if applicable) : _______________________________________ 13. Cause of death & : _______________________________________ Whether Attributable to military / coast guard service 14. Particulars of dependent children:Sl. Name No. 1. 2. 3. 4. 5. 6.

Gender

Date of Birth

It is certified that the above information is duly checked from the Discharge Book of ExServicemen / Ex-Coast Guard and found to be correct. Office Seal: Dir RSB/ZSB/OI/C Record Office / Coast Guard Headquarter Date: _______________________ Place: ______________________

CERTIFICATE FOR PM SCHOLARSHIP

1. It is certified that Ms. / Mr._____________________ is Bonafide

student of __________________________________ college. His / Her roll number is __________ and he / she is studying in the I / II / III / IV / V year or ______ semester of the One / Two / Three / Four / five years _______________ course in ____________________ branch (if any). He / she has joined this college in the academic year 20___ - ___ and the course will be completed in the month of ____________ 20___ -___.

2.

This is also certified that _____________ course is a professional course and this college is approved by

degree

________________________________________________.

3. This is also certified that student is getting Rs._____________ per month / year (If not getting write N/A) scholarship / stipend from this Institute / College or any other sources.

Office Seal:

Signature of Principal / Dean / Registrar

Date:- ______________ Place:-_____________

Note: Failure to attach bonafide certificate as per this specimen will lead to rejection of application. Amendment / Blank / use of whitener will not be accepted.

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PRIME MINISTERS SCHOLARSHIP SCHEME ACKNOWLEDGEMENT SLIP

OFFICE COPY

Your Application Form dated_________ has been received on__________.

The

application will be examined for eligibility. The dak receipt number ____________ is to be mentioned for further correspondence with this office.

Office Seal:

(Signature of RSB / Coast Guard Headquarter)

Tear off

Tear off

ACKNOWLEDGEMENT SLIP
STUDENT COPY

Your Application Form dated_________ has been received on__________.

The

application will be examined for eligibility. The dak receipt number ____________ is to be mentioned for further correspondence with this office.

Office Seal:

(Signature of RSB / Coast Guard Headquarter)

Note:

Student copy duly stamped and signed by RSB / Coast Guard Headquarter is to be given to the student by hand or by post. (Envelope enclosed alongwith the application may be used.) Office copy duly filled by the RSB/Coast Guard Hqs to be attached with the application.