Government of Karnataka
Department of Backward Classes Welfare
Student Application cum Verification Report for
Post-Matric/Food & Accomodation/Fee Concession (OR) Nursing Fresh
2019-20
1. Application No: 2019 0058 0599 2. Application Date: 13-10-2019 3. Caste Category / Caste: CAT-IIIB / Lingayath/Veerashiva-Veerashaiva Panchamasali(Sl.No-1-(b)))
4. Student Name : THIPPESWAMY G N 5. Gender : Male
6(a). Father Name : NARAPPA G B 6(b). Mother Name : RUDRAMMA
7. Address & Mobile No : LINGAYAT ,Holalkere , Ganjigatte ,CHITRADURGA & 99XXXXXX71
9. Pass Year: 2013-Karnataka
8. SSLC HT No : 20XXXXXXX07 10. Date of Birth: 05-05-1998
SSLC Board
11.Family Annual Income (in Rs.):
12. SATS ID : -NA- 12(a). Ration Card : HOL04120028
12000
13.College Details(college Nature) : PES UNIVERSITY COLLEGE BSK III STG BANGALORE , Bbmp,Bangalore Urban , (Residential) ,PES UNIVERSITY BSK III RD STG
BANGALORE
14. Course Name /Course Year /Duration of Course : M.Tech ( Civil Eng) / I Yr / 2 Yrs
15. College Admission No / Admission Date(of this year): / Admission
Through 20191003189 / 25-09-2019 / Government Quota
16. Distance (in Kms.) : 300
17. Scholarship Type : Day Scholar 18. Scholarship Applied for: 1.Post-Matric/Food & Accomodation,2.Fee Concession
19. Bank Name / IFSC Code: BANK OF INDIA /BKID0008967 20(a). Bank A/c No : XXXXXXXXXXX2640
(a).Income Caste Cert. No. :
(b).Cat-1 Caste Cert. No.: -NA- (c).Aadhaar No. / Name / Demo Aadhar Status: XXXXXXXX9230 / THIPPESWAMY G N / NOT DONE
RD203852XXXXXX8
I. Declaration and Aadhaar Consent
I hereby consent for the use of my Aadhaar number of XXXX / XXXX / 9230 , 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 .
Signature of the Student
Date :
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 M.Tech ( Civil Eng) / I Yr (Course & Course Year) during 2019-20 .
Signature of the Principal
Date :
(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
Yes No Yes No Yes No Yes No Yes No
Caste : Income: SSLC: TC: Ration Card:
SATS Yes No Yes No Bank Yes No Yes No Previous Yes No
Aadhaar: PHC:
ID: Passbook: Marks:
Other Details/Certificates if
any:
I recommend for sanction of :
Post-Matric/Food & Accomodation/Fee Concession (OR) Nursing
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
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October 13, 2019 04:10:07 PM
