Banishree new application form

Blank formats for Rayagada Block SSEPD Section.

1. /
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I-,nt:i-['i.a- A
+1PPI.IC-.i110_i:I._0Rju
{BANISIIRTH` -.,' Si.II{.Hi{. of S-ch{`il:H.sili|} l`or
Dig:ibled Stu{lentsj
(To be fille(I in b`-the calidi(I:it'LL-}
For the year .................
1. Nameinful]
(In Block Letter)
2. Address ...........
Village/Ward....................................P.S.........
G.P......-....-...................................
Block;NAC"unicipality...
District
3. Categoly o_f Disability as spee`ified
under RPwD Act, 2016 (Pl. menlit}n)
4. Arc you a citizen of lndia? {Pi. tic.i:) i/ } : Yesf:.-?`To
5. Whotller scheduled caste/ Tribe/ OBC/Gciieral
a?I. mention)
6. Male/ Female (Pl. mention)
7. Date of Bi[th (Pl. mention)
Name. and address oftlie father/ moth€rf-' gLti`rdian
9. (a) Re.l€ition.ship with the guardi€in {if ap|)liL`;lble)
(b) Total molithly income of the parems,.'` guai.di{`n
Nature of schol:lrship GJl. tic`k) { / 1
: i rresli,I.`` rcnc.al)
(a) I-Ia\'-|` }-.ou ever rcccived Scht}larsiiip
under an}J. other.scheme (i)I. tick,i i`. / ,i : TiJ`s,J' \{{i
(b} If};cs. indicate :
(i) Cl€ts{s in whii`h }f.riu ri`i`i`i\-ii,.i {!,\i` >]t.`;F{\il;i:.+ii;i.i
(ii) !'..`l`:.io{l fol. \`.!lii`h \-ou i.t`i.|]i\`t!i! `l!i`,:`* :+``Ltt.`i L `-`,ill :

2. 12. Ml.[1tion,
13.
i ``1 .
(a)C.Iassforhich1amappl}ingforsci-.`|.[ai.sh.ip
(b)AcadL`mic}'earofsuchclass
_ (c} Din.ti?. i+!1_which you got adnlissil`n
{a)ifyoiiarevisuall};challengedstudct`lindieate
[fyouha`'eongageclareader?(Pl.ticki{`/)
(b)1f}Jou.arcOfthopaedicallyH{andicappeiiStudent
being75%andiibovedisabilityindicatethe
mocic of transport.
Docunient :`tt2iclied:
(.hDisab~ilityCcrtit-lcatc(pl.tick)(/)
J::``ttfirlr_€hi-ptof|astExampassed{T:i.tick)'{/)
: yes/ NO
: Yes/ N(,
: yes/` NO
(ill M:'mrk-Sheet of last kxam pasbt:u \L ,h ,[`}`, ` , .,
i dcllarc ih.ri i tiz`\7G iiih rc:ii.ived (iioi i+c'`i\.;:i€) iiri; .`T)thcr stipcrtd' s.hf`!idrhliiL` i`j-`7i-ii
St{`te/C,¢ntral,Govcmmeltt.
Sigmiii!i.e a)f the sti!deiit
Pi;ic.,e.

3. LTD bc flllcd ill b}' Ilo:`d of Si.hool±_ C.ollege~`f''r F.dllcatiomtl lnstitution9
I certify that:
I The information furnished b}` the i`iindit±€ti€ {mme_ I \1+ \,-+ ,---.- `--_ _
_ ____ .~._._.a ..., ¢.._ ......-..- rT±.€Ti,ic-li€|`,n i..€i`ificd and ±`ouncl collect
I The school/ institutions in which the c=Hdidal€ is ^studying is Govemmenv recognized
____------,_
privateschoolfinstitutions(Pl.tick)(/`i\`;hicheverisapplicable.
I The application is recommended.
Sign.iture ot` Head tif [hc' Scho{il7' I nstitulion
Nanc
(in Block l^,,etler'}
Address
Pii`ce..............I................
Certiricate:
(only!ncaseofstudentwhodoesnot'Peioiig{LoBPLf:im.ily}
-i. I,
\`E,LIA'' I.-__`~_ _ __ _
Theparenta"familyincomeo±-the€ipp!ic:3n`iis"3tm(irethanRs.60`000/-perannum
Revc``nLic Inspector
{Signaturc ``'ith seal)
(To be rilled in b}r Sanctioliing Autliority')
I
I ha`'i` verified the infomiation as i`iim3shi`c! b} heiid it` the school/ institution. I hcreby'. , ,_:___ A.,I
tow.€irds sc.holar5hip and
sari_ctic`n Rs.
Rs.
totaii[18. to
t`l\al-d* {tcilcil`l-.i ;1!!C!\`..allcer mobilit}f suiipc}i.1`` thiu|.i
Sfinetion Order No.
Si¥i"t`ii.e with se:il of
Bl~`0/Siib~Co!lc{`,tor