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Government of Karnataka

Department of Backward Classes Welfare

Student Application cum Verification Report for
Post-Matric/Food & Accomodation Fresh 2014-15
Please COMPLETE Aadhaar Authentication by Clicking Here to start the VERIFICATION Process.

1. Application No: 2014 0083 7763

2. Application Date: 08-09-2014

3. Caste Category / Caste: CAT-IIIB / VeerashaivaLingayath(Sl.No-3-(a))

4. Student Name : SAGAR Y S

5. Gender : Male

6(a). Father Name : SURESHA Y H

6(b). Mother Name : SUJATHA Y S

7. Address & Mobile No : NEAR TEMPLE ,Harihar , Yakkegondi ,DAVANAGERE & 89XXXXXX95

8. SSLC HT No : 20XXXXXXX74

9. Pass Year: 2014-Karnataka SSLC Board

10. Date of Birth: 03-05-1998

11.Family Annual Income (in Rs.): 11000

12. SATS ID : -NA-

12(a). Ration Card : HRHR00127194

13.College Details(college Nature) : RURAL POLYTECHNIC HAUNSABHAVI(311) , Hirekerur,Haveri , (Private Aided College) ,Board of Technical Education

14. Course Name /Course Year /Duration of Course : DIP (AUTOMOBILE) / I Yr / 3 Yrs 

15. College Admission No / Admission Date(of this year): / Admission Through 9463 / 17-07-2014 / Government Quota

16. Distance (in Kms.) : 65

17. Scholarship Type : Day Scholar

18. Scholarship Applied for: 1.Post-Matric/Food & Accomodation

19. Bank Name / IFSC Code: VIJAYA BANK /VIJB0001075

20(a). Bank A/c No : XXXXXXXXXXX1951

(a).Income Caste Cert. No. :

(b).Cat-1 Caste Cert. No.: -NA-

(c).Aadhaar No. / Name / Demo Aadhar Status: XXXXXXXX1117 / -NA- / NOT DONE

.

I. Declaration and Aadhaar Consent

         I hereby consent for the use of my Aadhaar number of XXXX / XXXX / 1117 , provided in the application for Scholarship, to carryout Identity Validation,to make Direct Benefit Transfer of Scholarship to the Bank Account and also to seed the said Aadhaar number into ePASS Scholarship. Further, I also consent to obtain its Aadhaar Number and to use the Aadhaar number, so obtained, to carryout Identity validation and also to make Direct Benefit Transfer of Scholarship to the Bank Account."

         I hereby certify that that above information furnished is true. I have not availed any other scholarship for this purpose from any other sources. I shall abide by the terms and conditions of the sanction of the scholarship. If any discrepancies are found later, I hereby abide for refund of the scholarship amounts claimedand also am liable for action by the Department .

   
    Date : Signature of the Student
            
II.Verification Report of College Principal

        This is to certify that the information furnished above is verified with the records and found to be correct. He / She is a bonafide student of our college studying in DIP (AUTOMOBILE)  /  I Yr   (Course & Course Year) during 2014-15 .

   
    Date : Signature of the Principal
          (With College Seal)           
III.Verification Report of Verification Officer/ 
 

        I have verified the contents of scholarship  Fresh  application with reference to the college records and original certificates, physically identified the student verified the following certificates

Caste : Yes No Income: Yes No SSLC: Yes No TC: Yes No Ration Card: Yes No
SATS ID: Yes No Aadhaar: Yes No Bank Passbook: Yes No PHC: Yes No Previous Marks: Yes No
Other Details/Certificates if any:  
  I recommend for sanction of :
     Post-Matric/Food & Accomodation
 
  I do not recommend the sanction of scholarship for the following reasons. (Please specify)
   
  I have physically verified the SSLC Certificate in person
 
  Date : Signature of the Verification Officer