Annexure-1 (Revised 2020_21 )

OF -SE(ln lieu of OischafieEooQ(USE BLUE INK PEN ONLY)

UA ERT CA

_t_t.(dd/mm/yyyy)

Particulars of ALt

Note : - Scan anO uptoaOEx-serviceman.

Children includ the student a

Years &--Months

PMSSPMSS EarlierAvailed / Not

Availed

an affidavrt I self Grrlficate if the ward rs born after retirement / release ._rf

Category of ESM _ lFrlt up categoryassesstng the documents of fx-serviceman) _

Prioritv for Grant of Scholarship.Order of preference for selection of candidates will be as uncler:_

Yes / No lTick out)

1 to 6 as per priority given betow a r

(Srgnature of Secy ZSB/ DGCG)

(Rubber Stamp of Srgning Officer to be Affixed)

Type of Service lArmy /Navy / Air Force / Coast

Name of ESM

Date of Enrolment Date of Discharge iRetirement

Duration / Lengthof Service

PPO Number

Reason tor Oiscnarge I

ESM / Widow tdentitvCard Number & Date

ESM / Widow ldentity CarO iwhom (Write Name of ZSB

Born DuringService or After

Retirement

Date of Death oi Cause of Death

whether the d;ril-r / disability wuru1ffi;irtb t"fri#ryz.r*Guard Service ?

Round Stamp ofZSB Office

EF'

l

ll

Married /Unmarried

Category 1

Category 2

Category 3

Category 4

Category 5

Wards / Widows of ESM / Ex Coast Guard personnel killed in action.wards / widows of ESM./ F.r 9o.r..t crqno'p"rsonner disabred in action and boarded out of

3"grvige.wiltr disabirity attributabre to Miritary / coast Guard service.wards / widows of ESM./ Ex coast Guard personnet who died while in service for causesattributable to Military / Coast Guard Service.wards / widows ot rsu; r, c"r.i c;;;;';"rronner disabred in service with disabiritya.ttributable to Military / Coast Guard Service.wards / widows of ES-N/ / Ex coast C;r;J p;;r"nner in receipt of Gailantry AwardsWards / Widows of ESM I Ex Coast Guard narsonnct /pFl^e .\^r.,\

1' check particutars/oepenoabrlity of student in discharge book of ESM, proof for category, .1 0.,class certrficate/ nrark::ffi|:".,"??3;fl?3.::llliTj?-**:l*:1 LT- ;":;;"j;,'.-book (sBr/pNB) Annexure 2 & 3 and arrdav*,se,rcertificate if born after retirement before signing of this certificr,u ,o ,"L"JJ,ir?i!J"?, ;ffi:?':jr).ir;::,'? 'For'signature will not be acceptedi3' lt is certified that the above information is checked from the Discharge Book of Ex-Servrcemen i Ex-coast Guardpgl!

n registered with this ZSB/DGCG

I

I

I

I

I

I

FIDE CERT(usE sLue@

n,or

Annexure-2 (Revisect 2020_21 I

/ INSTITUTEeeru I WHiTilEny

Ms/Mr

Date

Place

lilgi-r,l': "l ES M/widow;rr:ame of ESM/WidowDate i \r_ (Srgnature_of Student)

Name of Student

,*ffJH sl

ii,"# : ru:,e.:'; ;, ;;;;;;::, ;lnstitute / Slaro

^^,,- jjl-'ll?nce from college /

I:l:,- Nor ro MENIoN rHE scHoLARSHtpAMOUNT OF 36,000/-oF pM Scr{(]r noo-,^(g5t sJ_& 30'000/- (BOys)

(a) Write yES / NO

[:H1;J stateCo,i ;,"il;';; ffi,:;J:j; i

Rsmentron total getting amount of

(b) tf YES,

,pr-J-.;;;:_; per month lyear tsemester*

l" ffi ::^'-,:l:":,, yi 1,., i,, "i'J;;l JJ'",J";you will not strike ort tn"

";,;;; ;ifi,,iffioF pM scHoLARSHrp scHEM; a^;;i assumed as monthly)

(Signature)

*?:ffH"d,,y:ffi[:J;r?i:iil,J,..:,r 't"nibre Rubber.^r,,r_or signrns orriciar must be arrixed).;;il"'+ffi *"_i:U"* o.,.I;;;il;ilJt'/ nusi.t,,,/rDire*or/Depu1y

1. (Studentr .*** krb.e;;; I ;G;;ert,|, iXIi Il^,*]_?^ read a r ru unoe rsrood the check_

lue" ra-GEFo'rlrJn'it"'rnat nrormar'|on p,o,ded nr r"',t"."o,.,..7,'r.'o'1,.J]',"01?,:i;ril:;:r'ons avarlao,e on vl(:hi,c

i, ," *i;#ffi,:1;:jJt1J,:t;:l'":ti:tij!1:1ru;::;:#' ;i:".:::,[" u.o, .u,,.n ,, j.iu *r:;:*i:"ri:^, t arn also ,,.oL1" .,"ir";;:'#i:"1::ffithat rtwririnvrte cnmrnaior".""J,rgl.pprrcatron ts rrabre to be relecteianJr

:':'";Ti;',:,j:.#l:9.j;:H*i:,,:;i:'''n'' amo'r'rt arreaoi, oa,d to me "",,.o,"o,,ry due to crericar error aro w,r,

bani' s^sp1.1'13t,on oass,ns;ul.,ii.u]u: ;:Xi r]iJ"!-:- tcate semester wrs6

,^ --. '.tn,lv;;;;;;-.."" submitted onry one uoo,'ll. a aaonaar;;;; ;';;;Xl'r'l':;,j";1'|oe cert'r'|care ce'1'rcare',o.i

;:'"t'i: ,::liffi ff SJ,"..ron*1" roi,r-,l .rr."p

rcatron rr dupricate apptica'tion . r"*i.i"rilil, apprrcatrons are rrabre to be

1uemei ;. s;, ;h"i:;;;l:iiilT8 T:::"J"'.:::orarsn,p S_cr.ene pMSS

;';t ;ulE'Jft: g?xf"silv'Bf[., :,..f.:r*r,i*n"il;:]"'::yl":;J"?:#::iJ'; ,;'::; l"' ;:;ili? ::i'":: lil;:., i il*ii, i,5"};ig,*[{Eii'},fiHti#l{*=",'" ;; ; ;ffi : ; -,;, n :'

r" " n" ,'' ip

I p ease carrv ,o- .1,?311.#:j L':x:i1",T1.::7'?::in';ii;'J?"?"".::.-;';#.'b?H'.?!',u. D,,.".,o. Dv D recro

; " ?:?J;Jfl:,ir#:::ir*:-':glm#ii:[:."*;';4ln*i":=,:;::,:J""' .r ca,es.,v a nnneru,e z a :atron brochure avartable wih Ztla Sl,nlf,"s;rro and Websrte

!-(

fVame of StuOent

Name o-olregeName oic"urs" 6l rorrlName or ararrcustre--__:_ am oI Course f if anyt

*H,:l 9qr rs1 n u gr., la vLatera i/corr:ellstE;ed;ffiffiailHl*: pard to collese at the time orStuoyngln th!-a.iJ 2,,d 7aa l4n,earStudyrng rn indra / Abroad

(a)_yeais(b) Academic year

{a) }e1s; Course Duration {ln years;

ll,, i:10:I:c,y9ar of admrssron taken1:l ?ate of Admissron in Coilege(d) Date of Course C,,:, ; _,_.______omqletion (Tentative)iar Regrum(b) Coltege / lnstitu[e is aifitiateO to

,", ll,:1_I?"l gf the Unrvers;i;; '"L?^- ryn etle{qEg{-Illrt"ii

nrtonomo us ?

UGC/AlCTEIMCtretct

!1I:. r No (rick out)

bt7Date

fb

Annexure-3 (Revised 2020_21 )

USE BLUE INKFENbffi1.

2.

3.

4q

Name of StudentName of ESM / WidowAccount number of StudentAadhaar number of StudentName of Bank: Branch Nameo. tt is certified tn"trtffi;;; ;;.,l;;dL

IFS Codebeen linked with above Savingcompliant.'Balance Exceedsremoved from the Account.

Bank Account Numberall Maximum Lrmit is

__-/ (Signature of Branch Manager)Officiat Stamp

lr,rrlr''"[L *' ''"'o," tne rorro*i

lfilling-upOnlineApplicationi;;pMIS-r'rq gurqerrnes oI PMSS and ensured the following actions white

I(a) Para 1(d) I hiffio ,p my J*n Aadhaar Number correcuy.(b) Para 2. Gender nas Oeen ,"1""t"0'."rrecfly.

l:] ffii:l1i;!-lf6r:llsi;i:lil# Ji#:#en correc,v ri,,ed up and ,wi, not chanse(d) Para 10(a)' Minimum Educationar di,ariricatiol rrvEoin", been serected correcry.(e) Para 10(b)' year in which ;y;;il; exam /MEe prr."o has been correcly filed up.

ll ffir9-",';:liffiiT,iJ:"#*1;,31:l;#?::l'J#e & printed on mark sheet ror which J(g) Para 10(d)' 'ruarks obtaineJ

"il l'ri"ruor"cts of rast ex;;/MEe of a, semesters/academic yearhave been filled up correctly' All subjects m9r1. -"ir ,rl;".t, visibre & printed on mark sheet for I

,n, HXI?n,T,,lL,#::*:::f1fo 3,ii"not out or best subjects Ih) para 12 Name or course ;"r;.t;i;;;:"JdHL:""".,1 :Jffi:?." certrricateg) Para 14(a) Date of admission in .*r." nis oe6n .orru.tiy fired up(k) Para 14(b) course commencing date has been fired up correcry(l) Para 17(al Name of student ls ounr. account hotdlr ias

9ee1 .correcily fired up My Bank

,_, Ai:;}_fi?fiffl,;T:;-*H,Ii,"ilffiffi", #.l"li"uuo. a, Maximum Limit, is removed(m) Para 17(b). Bank nrru r"rirlu"n ,"ui".,uo correcily{n)

*ffi9;oory$i:X",lU,'#m',"t*,"*;,:Sl- pass Book has been correcry ri,ed up r(o) Para 17(el IFSC code hai nu* iiri"o ,p .or".try as given in Bank pass Book No specralcharacter is rncruded in rFSC .oJu unJ rii,"o ,. n,'*.lnL'rnr. pass Book.tmportant Name of loint ,..orni noiolr lfather oi ir"irr"rj n'J,,, ou fired up(p) I am pursuing integrated course. I have read and unoerstolo the poricy on integrated courses

, S:i,l?ii:ril itS#::,:i:,ffi#ffitr* under prvts - wew Rpfrication-]- How to Appry ror(q) I have taken admission in ..^r^".,^11,

(it]'^"-llA if not applicable)(q) I have taken admission rn pi"i"'ri"."';;;,;:^.';;,:'"'?f ;B?L",rno ,,"renry studyins in r.( 0, ] ff ; ll l,'r' R: 3 " "'' :T ? ;1 : 1,,! ",1:,: -ii

=

1;i 51t y-i", " " r\r 'r I drr I gerlng Ks

-

as financial assistance rro* dtn"r sources (other than pMSS amountfrom KSB) as mentionEd in oonarioe certiricaie ail il; amount is arso fiued up atpara 11(a).

i", iii:!X3i1f;Hi: Uf?,3j"S,,:;,?::i,J;J,,olL,iJ',ir,orouJ,g "in,rr p",ribn or oocum"it o,.

iu"trl?lir8i;$irt;:ru;'.*i;ioi[5t"go,v 1c,t*sory 1 to 5 (parr rr order) and ror catesory - 64- I wilr save schorarship-amiunt and date immediaterr,corumn No 14 or RenewarAppricatio, yH*,;,jii.r#:J;J.:"-'r"J*1"Tr:ils?:t rrom KSB in5 l have forwarded fl.,e a'p[iicJL-n'onrine on (sa p,irtur ,to ,y zse an;-ii'ls not pending rn mydashboard' lwill be rrero res[on"oi"'ii it",rr" not "ru"ir"nl'ro*rio"d it. rwi, be herd responsibre forrejection of apprication due to'no, ,J-n"r7rnry of above mentioned instructions.

Round Stampof Bank Branch

(Signature of Ex-serviceman)

/,O$ionrture of Student)