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Fresh Application Backward Classes & Minorities Welfare Dept.

Madhya Pradesh Scholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2020-21
Applicant Unique ID: 4122107 Scheme : Post Metric Scholarship for OBC
Application ID: 5904372 First Time Lock Date: 31/01/2021
Version No: 2 Verification Code: 4307 Lock Date: 09/09/2021 IPAddress : 122.168.57.10
Instructions for colleges & offices: Please check all information in each section and place a tick mark in on the box. Institute
will use the first Box with I sign and Sanctioning Office will use second box with O sign in it.
Institute : [20379],Samrat Ashok Technological Institute (Degree), Vidisha District: Course : B.Tech/A.I. & Data Science/1st Year [9698]
VIDISHA

Old Scholarship Details(Before 2014-15 No Post Metric Scholarship was sanctioned Last Year.

Details Application Form 10th Board Data Samagra Data Counselling Data
Name GODAVARI PATLE GODAVARI PATLE GODAVARI PATLE

Father/ Husband Name DAKCHARAN PATLE DAKCHARAN PATLE Dakcharan Patie

DOB 13/11/2002 13/11/2002

Gender Female[˜Ǒ¡›ȡ%
Category OBC #\ͪ”% OBC #\ͪ”%

Religion : Hindu Special Category : No Voter ID : -- I O

Aadhar No. : XXXXXXXX0035

2. Details As Per Digital

Caste Certificate : Reg No: RS/457/0106/57795/2014, Name : GODAVARI PATLE, Father I O
Name : DAKCHARAN PATLE, Mother Name : REKHA BAI, Category : OBC, Caste : Panwar

3.Academic Details As Repoted by Student : Enrollment No. : 0108AI021015 Admission Date :22/10/2020 I O

Details As Repoted by Student Counselling Details

Admission Mode College Level Counselling

Institute [20379],Samrat Ashok Technological Institute (Degree),

Vidisha District: VIDISHA
Course B.Tech/A.I. & Data Science/1st Year [9698]

Academic Year 2020-21

Hostel Admission Institute Hostel20/10/2020 --

Last Year Exam Details : Exam Name: MP BOARD, Exam Date : 02/03/2020
I O
School./Institute :GOVT H S SCHOOL KUNDAMOHGAON BALAGHAT Result : PASS

Post Metric Scholarship Details Generated From Scholarship Portal

S.No Academic Institute Course Br Yr Scheme Admission Hostel TFW Income

Tear Mode status
1 2020-21 20379-Samrat Ashok 97-B.Tech/9698-A.I. OBC College Yes No 30000
& Data Science/1st
Technological Institute Level
Year
(Degree), Vidisha

Error: Subreport could not be shown.

4. 10th Board Details 10th Board Name: MP Board of Secondary Education, Year: 2017-2018, Roll No.: 187826373 I O

5. Total Annual Family Income : Rs.30000/- Income Certificate : issued by-TAHSILDAR ON : 02/07/2018

Generated by Scholarship Portal as on 09/09/2021

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Fresh Application Backward Classes & Minorities Welfare Dept.

Madhya Pradesh Scholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2020-21
Applicant Unique ID: 4122107 Scheme : Post Metric Scholarship for OBC
Application ID: 5904372 First Time Lock Date: 31/01/2021
Version No: 2 Verification Code: 4307 Lock Date: 09/09/2021 IPAddress : 122.168.57.10
Father/ Husband Occupation : Farmer / Agriculture, Income: 30000/-
Mother Occupation : House Wife ,Income: 0/- I O
Other Income : Rs.0/-

6. Contact Details Mobile No : 8319635107 godavarirdp[AT]gmail[DOT]com I O

Correspondance Address : ward 16 gram kunde post kariyadand tahsil kirnapur dist balaghat Kunde, District :- BALAGHAT

Permanent Address : ward 16, gram kunde post kariyadand tahsil kirnapur dist balaghat Kunde, District :- BALAGHAT
7. Bank Account No: 33566881081, IFS Code: SBIN0006964, STATE BANK OF INDIA, LINGA (NAVEGAON), BALAGHAT I O
8. Change History NIL I O
ALERT: Details of Applications already registered by using same Samagra ID :
Nil
ALERT: Details of Applications already registered by using same 10th Board Roll No :
Nil

]ȯ‘€fȲ\ͧ——ȡ€”ȡ›€€ȧƒȪŸŽȡDeclaration from Student and Parent/ Guardian

1. We, GODAVARI PATLE S/D/W/o DAKCHARAN PATLE and DAKCHARAN PATLE hereby declare that Board Roll No, Samagra ID, caste
certificate and income certificate, bank account details and all other information given in the application form is complete and correct. We have not
submitted any other application for scholarship for current academic year in any other institution in India. We also undertake that, if any information
given above is found to be false at any stage, entire amount of scholarship will be recovered and competent authority will be free to initiate legal penal
action against us.
¡˜GODAVARI PATLE S/D/W/o DAKCHARAN PATLE kšDAKCHARAN PATLE ƒȪŸŽȡ€šȯ¡ɇ
ͩ€`”šȪƠ‡ȡ“€ȡšȣ ¡ȣ¡ȰfȲ ˜Ē]_ŒȢ€¢ȡCB–ȪŒ[”šȣ¢ȡ€ȧ˜ȡ€[žȢŠ‡ȡǓȡ]™Ĥ˜ȡŽ”ğ–ɇ€\€ȡ`ȲŠȡ\ۙ
ͪšŽ”ǗŽ[fȲ ¡ȣ¡Ȱ@]ȯ‘€“ȯ”ȪŠ[›”š^  ğ˜ȯè€Ȫ›šͧž”€ȯͧ›f€ȯ›f€¡ȣ]ȯ‘“ͩ€™ȡ¡Ȱ@\‚š`”šȪƠ‡ȡ“€ȡšȣ‚›”ȡ_
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™Ǒ‘]”‚›Ø™ɉ€ȯ]’ȡš”š†ȡğǙǓ›ȯȯ¡Ǖ]”ȡf‚™ȯȪ¡˜ȡšȣ†ȡğǙͪƣǓ“šè€š‘ȣ‡ȡȯ‚Ȣȡ†ȡğǙͪƣ€ȧǔ‡“Ȣš€˜‘ȣ‚_
¡Ȱ` ȯȡ” ›ȯ›ȣ‡ȡȯ‚Ȣ)^ š¡€ȯͩЙȡ€›ȡ” ȯ ˜ǔےͪ’ȡȸ€Ȫ¡˜ȯžȡ€ȯͧ›fͩ€ Ȣ—Ȣ™Ȫ‡“ȡ€ȯ\ۏ‚[ͩ€ Ȣ—Ȣ†ȡğǙͪƣ
 ȯͪǔ‡[
ŒȢȡš€šǑ‘™ȡ‡ȡ™ȯ‚ȡȡͪ’ȡȸ€Ȫ€ȡ›ȣ Ǘ…Ȣ
ޛȰ€ͧ›èŠ˜ɅŒȡ›Ǒ‘™ȡ‡ȡ™ȯ‚ȡȡ†ȡğǙͪƣèȢ€Ǚ€ȡ[\ͬ’€ȡšȣ\ȡ
\ۙ ¢˜\ͬ’€ȡšȣ]æ™€ ˜ˆȯ‚ɅȪ` €ȯͪǽڑ—ȡšȢ™‘ÖŒ ȲǑ¡ȡ€ȧ’ȡšȡjȲfȲ€ȯ¡
f•]_]š‘‡[€šȡ_‡ȡ€š É€ȡ™[ȡ¡ȣ€ȧ‡ȡȯ‚Ȣ)
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†ȡğǙͪƣžȡ “€Ȫ Ȳ–Ȳͬ’ǔ‡›ȡ€ȡ™ȡ[›™€ȯ˜ȡڙ˜ ȯ…ȡ›ȡ“ ȯȡ” €š‘Ǘȱ‚ȡ‘ǗȲ‚Ȣ)†ȡğǙͪƣȡ” “€š“ȯ€ȧǔèǓ˜Ʌžȡ “˜ȯšȯ
ͪǽƨ€Ȫ_—Ȣ€ȡ™[ȡ¡ȣ€š“ȯ€ȯͧ›™ȯ蝏Ȳğš¡ȯ‚ȡ)

\ͧ——ȡ€”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate ( ]ȯ‘€€ȯ¡èȡ¢š

Declaration from Institute Head & Institute Scholarship Nodal Officer
We, hereby, certify that the student is enrolled in the approved course of Govt MP. All the details filled by the student in the above application
form have been verified with the original documents and have been found to be correct and authentic. He/ She has passed last exam and is eligible
for sanction of scholarship. College has ORIGINAL COPY of his School Leaving Certificate. His / Her attendance is regular, as per the instructions of
Government
We have verified all details as per te scheme guidlelines & instructions and recommend him/ her for sanction of scholarship as per the rules. We
also undertake that, if the above student does not attend the classes regularly or discontinues the course, We will immediately report the matter
to the concerned district office so that his scholarship can be put on hold. In case any information of found to be incorrect, Government will be
free to initiate action against the institute.
The institute is accredited by the Government and permission is given to conduct related course.

(Signature ) (Signature ) Date (Signature )

Scholarship Nodal Officer HOD Director/Prinicpal

Generated by Scholarship Portal as on 09/09/2021

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Fresh Application Backward Classes & Minorities Welfare Dept.

Madhya Pradesh Scholarship Portal 2.0
Integrated Scholarship Application form- Post Matric Scholarships for year 2020-21
Applicant Unique ID: 4122107 Scheme : Post Metric Scholarship for OBC
Application ID: 5904372 First Time Lock Date: 31/01/2021
Version No: 2 Verification Code: 4307 Lock Date: 09/09/2021 IPAddress : 122.168.57.10

Your 10th Board Details 10th

Board Name: MP Board of
Secondary Education, Year: 2017-
2018, Roll No.: 187826373

(Signature of Parent / ”ȡ›€ͪ”ȡ€ȯ¡èȡ¢šDate (Signature of Student / ]ȯ‘€€ȯ¡èȡ¢š

“ȪŠ†ȡğ†ȡğȡ€ȯ]ȯ‘“•Ȩ˜[”š™Ǒ‘€¢ȡȢ€ȡͪšŽ`”›Þ’“¡ȣȲ¡Ȫ“ȯ”š ȲèȡĤ˜Ǖ†ȡğ†ȡğȡ€ȯȢ€ȧ˜Ǘ›ĤǓ
˜ȡ€[žȢŠ ȯ
‡ȡ“€ȡšȣ ×™ȡͪ”€šȯ)

Generated by Scholarship Portal as on 09/09/2021