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PRIME MINISTER’S 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: This 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.)
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COLUMN WISE GUIDE LINES FOR FILLING UP OF APPLICATION FORM

(i) Column -1. Fill your name as in matriculation certificate only:-

(Not to be filled in any other format.)

1st Name A J A Y
Middle Name S I N G H
Surname R A N A

(ii) Column -2. Put a tick (√) mark as shown.

Male √ Female

(iii) Column – 3. Date of Birth as shown in matriculation certificate only.

For Example:- (10 June 1982)

D D M M Y Y Y Y
1 0 0 6 1 9 8 2

(iv) Column – 4. Mention your Rajya Sainik Board and Zila Sainik Board name,
from where your father / mother have registered and have obtained ex-servicemen /
widow identity card (Not for Ex-Coast Guard).

(v) Column – 5. Write your permanent address and correspondence address in

block letters.

(vi) Column – 6. Write phone number along with STD code and email ID for any
query (email ID is must).

(vii) Column – 7. Category as per para 6 to be written (attach the required

document, if any). Category 1 (One).

Category - 1 O N E

(viii) Column – 8. Full Particulars of Father/ Ex-Serviceman / Ex-Coast Guard is

to be mentioned as per the discharge book. A blank space to be provided
between names. (Example: - KAMLESH CHANDRA CHOUDHURY)
K A M L E S H C H A N D R A C H O U D H U R Y

1 4 5 2 3 6 K

S E R G E A N T

A I R F O R C E

(ix) Column – 9. Details of 10+2 or MEQ. Leave blank space between words.
Marks to be shown in words and figures.
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a. Total Marks O N E T H O U S A N D
(in words) T W O H U N D R E D
(in figure) 1 2 0 0

b. Marks obtained N I N E H U N D R E D
(in words) F O R T Y
(in figure) 9 4 0

c. % of marks scored S E V E N T Y E I G H T
(in words) P O I N T T H I R T Y
T H R E E
(in figure) 7 8 . 3 3

(x) Column – 10. Tick as applicale.

Yes √ No

(xi) Column – 11. The student is to specify the course which he / she is presently
studying. (Example:- B TECH)

B T E C H

(xii) Column – 12. Duration of the course both in numbers and figures to be
mentioned (without Internship). For example 4 years 6 months.

(In figure)
Y Y M M
0 4 0 6

(In word)
F O U R Y E A R S A N D S I X
M O N T H S

(xiii) Column – 13. Write date of commencement & completion of course as shown
below:

(Course Commencement / Date of Admission)

D D M M Y Y Y Y
0 1 0 7 2 0 0 7
(Course completion)
D D M M Y Y Y Y
3 1 1 2 2 0 1 2

(xiv) Column - 14 Write the full name and address of the college with email ID and
phone number of principal.
Name of Student A J A Y S I N G H R A N A

Roll No. 0 8 E A T I T 0 4 3

Name of College A J M E R I N S T I T U T E
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O F T E C H N O L O G Y

Full Address P U S H K A R B Y P A S S A
of college J M E R

State R A J A S T H A N

Pin Code 3 0 5 0 0 4

Tel No. (with STD Code) 0 1 4 5 - 2 3 0 0 6 2 8

E-Mail ID (if any) a i t _ a j m e r @ r e d i f f m a i

l . c o M

College Website w w w . a i t a j m e r . c o m

(xv) Column - 15 Write the regulatory body of your college.

A I C T E

(xvi) Column – 16. Furnish the particulars of your all children as per specimen
given:-

Sl. No. Name of Child Gender Date of Birth Age

1 Prakash Singh Rana M 10/10/1982 27 Years
2. Satish Singh Rana M 12/05/1984 25 Years
3. Ajay Singh Rana M 03/07/1987 22 Years
4. Komal Rana F 14/02/1989 20 Years

(xvii) Column – 17. Given details of the scholarship availed by your brother /
sister in the past, if not availed write Not Applicable.
Sl. Selection Name of the Course of Academic year Amount
No. Serial No. brother/sister Study in which received so far
given by KSB applied
1. 6359 Satish Singh Rana B Tech 2007-09 15000

(xviii) Column – 18. Fill up attached Postal Order particulars.

Postal Order No. 0 2 3 1 5 0

Issue D D M M Y Y Y Y
Amount (Rs.) in figure 3 0 Date 1 4 1 2 2 0 1 0

Amount (Rs.) in word T H I R T Y

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Note: Application form from page number 13 to 19 alongwith required documents
only to be forwarded.

CHECK LIST OF DOCUMENTS TO BE ATTACHED WITH

THE APPLICATION FORM

1. Candidates / ESM / Ex-Coast Guard are to ensure that the following documents
are attached (as applicable) along with the Application Form (non submission of these
certificate will lead to rejection and application will be returned unactioned).

(a) Attested copy of Ex-Serviceman / Ex-Coast Guard & Widow I-card issued by
RSB / ZSB / Coast Guard Headquarter.
This is an important document to be attached.

(b) Extract of ESM / Ex-Coast Guard discharge book as per specimen.

(c) If child born after discharge then affidavit is to be submitted by ESM / Ex-Coast
Guard, that child is dependent on him and he / she is a ward of ESM / Ex-Coast Guard.

(d) Additional Certificates – Attested copy of following documents.

(i) Category 1: Part II Order Equivalent of other

(ii) Category 2: Part II Order services i.e. Army /
(iii) Category 3: Part II Order Navy / Air Force / Coast
(iv) Category 4: Part II Order Guard
(v) Category 5: Award Certificate
alongwith gazette
notification
(e) Attested photocopy of matriculation or equivalent examination certificate for
verification of date of birth.

(f) Attested photocopy of mark sheet of MEQ as applicable (e.g. 10 plus 2,

graduation / diploma etc). In case the MEQ is graduation / diploma, then complete mark
sheet is required to be submitted.

(g) In case of MBA / MCA applicants, attested copy of minimum entry qualification
certificate. i.e Graduation

(h) Bonafide studentship certificate to be issued by Registrar / Dean / Principal of

College / Institution pertaining to course for which scholarship is claimed (As per specimen
attach).

(i) Postal Order of Rs. 30/- (Rupees Thirty only) attached. (Application form without
Postal Order will not be processed and Postal Order should not be made before 01st
January 2011.)

Date: _____________________

_______________________________
Place: ____________________ Full Name & Signature of Candidate
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_______________________________________
Checked / counter singed by ESM / Ex-Coast Guard / Widow

FOR OFFICIAL (KSB) USE ONLY

Signature of Supervisor/ IC PMSS Remarks of Supervisor

___________________________ _______________________________

_______________________________

_______________________________

RECOMMENDED / NOT RECOMMENDED

Remarks of JD PMSS

_______________________________

Signature of JD PMSS _______________________________

____________________ ______________________________

__________________________________________________________________________

Selection Serial Number

(To be allotted by KSB) ......................
APPLICATION FOR PRIME MINISTER’S SCHOLARSHIP FOR THE YEAR 2010 - 11 ___.
Recent
Photograph
Note: 1.) Please read column wise guide lines carefully before filing the application Of Student
2.) Application Form to be filled in Capital letters except email ID. (Write your name &
3.) Checklist must be attached on the top of application duly tick marked. ESM/Ex-Coast
4.) One candidate to submit only one application form for one course. Guard/widow
particular on
reverse)

1. NAME:-
First Name

Middle Name

Surname
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2. Put a tick mark (√) Male Female

LEAVE BLANK SPACE BETWEEN WORDS

3. Date of Birth (please attach proof of age) (i.e : Matriculation certificate)
DD MM Y Y Y Y

4. Your Rajya Sainik Board or Zila Sainik Board (Where ESM is registered and obtained Ex-
servicemen 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.

Street No. & Name

Tehsil

District

State

Pin Code
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b) Permanent Address :-

House No.

Street No. & Name

LEAVE BLANK SPACE BETWEEN WORDS

Tehsil

District

State

Pin Code

6. Telephone Number.

STD Code

Land Line No.

Mobile No.

E-Mail (mandatory)

7. Ex-servicemen / Ex-Coast Guard Category - (Mention category as per Para 6 of the brochure
and attach supporting documents duly attested).

8. Ex-serviceman’s / Ex-Coast Guard’s Particulars:-

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

b) Service No.

c) Rank

d) Type of Service (Tick one) Army Air Force Navy Coast Guard

9. Details of MEQ / course for qualifying examination for scholarship (10+2/equivalent

or minimum entry qualification)
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a. Name of Course/MEQ

b. Year in which exam passed

c. Total Marks (in words)

(in figure)

LEAVE BLANK SPACE BETWEEN WORDS

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

Yes No Rs (per month / year)

11. Name of the Course

(as per specimen)

12. Duration of Course in Years in figure

and months
in words

13. Date of Commencement and Approximate Date of Completion.

D D M M Y Y Y Y
a) Course commenced on

D D M M Y Y Y Y
b) Course completion date
approximately

14. Details of College / Institute.

Name of Student

Roll No.

Name of College
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Full Address
of college

LEAVE BLANK SPACE BETWEEN WORDS

State

Pin Code

Tel No. (with

STD Code)

E-Mail ID (if any)

College Website

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. Furnish particulars of all children in order of age, as reflected in the discharge
book or attached a certificate in case child born after discharge, by the RSB / ZSB /
Record Office / Coast Guard Headquarter, as applicable.

Sl. No. Name of Child Gender Date of Birth

17. Details of brother/sister availing the PM’s Scholarship, if any. (Including yourself if
granted earlier)

Sl. Selection Name of the Course of Academic year Amount

No. Serial No. brother/sister Study in which received so far
given by KSB applied

18. Details of Postal Order.

Postal Order No.

Issue D D M M Y Y Y Y
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Amount (Rs.) in figure Date

Amount (Rs.) in word

LEAVE BLANK SPACE BETWEEN WORDS

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 PM’s
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: (Signature of ward) _____________________________

Date: (Full Name of Ward) _____________________________

Place: (Signature of Parent) ____________________________

Date: (Full Name of Parent) ___________________________

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CERTIFICATE FROM RSB / ZSB /

DIRECTORATE GENERAL OF COAST GUARD

“It is certified that PM Scholarship application form for academic year 2010 - 11 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

RSB / ZSB / Coast Guard Headquarter

Place: ________________

Date : ________________
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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

degree course and this college is approved by
________________________________________________.

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

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Date:- ______________

Place:-_____________

SPECIMEN COPY OF EX-SERVICEMEN / EX-COAST GUARD CERTIFICATE

EX-SERVICEMEN / EX-COAST GUARD CERTIFICATE
(In lieu of Discharge Book)

1. Type of :
_______________________________________
Service (Army, Navy, Air Force or Coast Guard)
2. Service No. :
_______________________________________

3. Rank :
_______________________________________

4. Name & Initials :

_______________________________________

5. Trade :
_______________________________________

6. Date of enrolment :
_______________________________________

7. Date of Discharge :
_______________________________________

8. Reason for Discharge :

_______________________________________

9. Duration/Length of Service :
_______________________________________

10. Regular :
_______________________________________
Reserve

11. ESM / Ex-coast Guard died on (if applicable):

_______________________________________

12. Cause of death & :

_______________________________________
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Whether Attributable to military / coast guard service

13. Particulars of dependent children:-

Sl. Name Gender Date of Birth
No.
1.
2.
3.
4.
5.
6.

It is certified that the above information is duly checked from the discharge book of Ex-
servicemen / Ex-Coast Guard and found to be correct.

Office Seal:

Dir RSB/ZSB/OI/C Record Office

/ Coast Guard Headquarter

Date: ________________________

Place: ______________________

IMPORTANT INSTRUCTION FOR RENEWAL FORM

1. Minimum Marks for Renewal of Scholarship.

The candidates should have secured a minimum of 50% marks, uninterrupted for
continuation of scholarship in every year for the duration of course up to a maximum period of
5 years as prescribed for that programme of study. A person granted scholarship for one
programme would not be entitled for scholarship for another programme.

* Note:- If the marks in the qualifying examination are expressed in grades only,
then equivalent percentage (100 point scale) duly certified by the concerned college /
Board must be furnished (RSB, Coast Guard Headquarter & KSB will not be calculating
the percentage of marks).

2. Account Details.
All candidates to open individual bank accounts in the nearest State Bank of India branch
or Punjab National Bank which has “electronic clearance system” / Core Banking, to
facilitate transfer of the scholarship amount. Account number of the sister concern bank will
not be accepted. i.e State Bank of Travancore, State Bank of Bikaner & Jaipur, etc.
Candidate to attach a attested photocopy of passbook, showing name and account number
of the individual. A cancelled leaflet of a blank crossed cheque will duly authenticate the
account number. A joint account with parent will also fulfill the requirement.
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DOCUMENTS TO BE ATTACHED WITH RENEWAL FORM:

(a) A Bonafide certificate from the College/Institute indicating that the candidate continues
to study in the subject course and showing his / her percentage of marks for which the
Prime Minister’s Scholarship has been sought (As per the specimen attach).

(b) Photocopy of passbook showing name, account number with photograph of

individual and cancelled leaflet cheque. (Scholarship will not be sent in absence of
photocopy of passbook)

(c) Candidate to attach a self addressed envelope, duly stamped to receive the
acknowledgement of renewal form by post.

________________________________
Full Name & Signature of the Candidate

PRIME MINISTER’S SCHOLARSHIP SCHEME

ACKNOWLEDGEMENT SLIP
OFFICE COPY

Your Renewal 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
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STUDENT COPY

Your Renewal 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: This copy duly stamped and signed by RSB / Coast Guard Headquarter is to be
given to the student by hand or by post.

Selection Serial Number......................

PROFORMA FOR RENEWAL OF SCHOLARSHIP UNDER PRIME MINISTER’S
SCHOLARSHIP SCHEME
(To be send only if selected for scholarship)

1. Name of the applicant (Ward/widow):

2. Put a tick mark (√) Male Female

3. Selection serial No. given by KSB:

4. Particular of ESM / Ex-Coast Guard:

Name of ESM /
Ex-Coast Guard
Rank
Service Number

5. Present address (where you want your letter is to be sent)

(To be filled up only in case of change from previous address or write N / A)
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House No.

Street No. & Name

Tehsil & Post

Distt
State

Pin Code

6. Details of Bank account of SBI or PNB for Electronic Clearing Services ( (PLEASE ATTACH A
PHOTOCOPY OF PASS BOOK, CROSSED BLANK CHEQUE SHOWING YOUR ACCOUNT NUMBER TO
BE FORWARDED, EVEN IT IS SUBMITTED EARLIER).

Name of account holder

Bank Name

LEAVE BLANK SPACE BETWEEN WORDS

Branch Name

Branch Address

State

Bank Tel. No.

Branch Code

MICR (9 digit) No.

(PLEASE ATTACH A PHOTOCOPY OF CHEQUE & PASS BOOK)

Account No.

REPEAT

Account No.
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Place:_____________________ ________________________________

Date:______________________ Full Name & Signature of the ward / widow

It is certify that the information submitted by my child / self is correct.

Place :_____________________ _____________________________

Date :_____________________ Full Name & Signature of the Parent

LEAVE BLANK SPACE BETWEEN WORDS

Please Fill Properly Your Full Year (Both Semester’s) Marks

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

student of __________________________________ college. He / she is
studying in the I / II / III / IV / V year of the two / three / four / five years
_______________ course. He / she had 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 Ms. / Mr. ___________________________

__________ has successfully completed his / her 1st / 2nd / 3rd / 4th / 5th year
and scored
Year Marks Obtained Out of Percentage

1st Year (1st & 2nd sem) ____________ ______ _________

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nd rd th
2 Year (3 & 4 sem) ____________ ______
_________
3rd Year (5th & 6th sem) ____________ ______ _________
4th Year (7th & 8th sem) ____________ ______ _________
5th Year (9th and 10th sem) ____________ ______ _________

3. He / she is continuing the course in 2nd / 3rd / 4th / 5th year.

4. 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: _______________