Government of West Bengal

Office of the DWO, KOLKATA District

APPLICATION FOR POST MATRIC SCHOLARSHIP TO SC/ST / OBC STUDENTS (AY: 2025-26)
NEW/RENEWAL Application Serial No. : WB030218303311

1. Full Name of Applicant Shri/Kumari : JASMIN RIYA

2. Father's/Husband's Name : LATE ABDUL ZABBAR.
4. Date of
3. Gender : Female : 1998-01-21
Birth
5. Nationality : INDIAN
7. Telephone
6. Aadhar No : XXXXXXXX5167 : 8159836606
No.

b). Marital
a). E-mail Address : [email protected] : Un-married
Status

8. a) Caste : OBC A b) Sub-Caste : NASHYA-SEKH

c) Caste Certificate No : WB0502OBC201501578 d) Dated : 2015-04-02
e) Issuing Authority,
: SDO Gangarampur, DAKSHIN DINAJPUR District
District
f) Religion : Muslim
9. a)State to which applicant actually belongs : West Bengal
b) Permanent Address : VILL- BORA, PO- DANAGRAM, PS- HARIRAMPUR, DIST- DAKSHIN DINAJPUR
P.O. P.S. District PIN
Danagram BO HARIRAMPUR DAKSHIN DINAJPUR 733125
c) Present Address : VILL- BORA, PO- DANAGRAM, PS- HARIRAMPUR, DIST- DAKSHIN DINAJPUR
P.O. P.S. District PIN
Danagram BO HARIRAMPUR DAKSHIN DINAJPUR 733125
d) Whether in full time employment : No
e) Children with Special Needs (CWSN) /Person with Disability (PWD) : No
f) Percentage of Disability :
10. Particulars regarding MOTHER who supports in applicant’s studies
a) Name : SALEMA KHATUN
b) Occupation (if employed, give income certificate from the
: FARMER
Employer)
VILL- BORA, PO- DANAGRAM, PS- HARIRAMPUR,
c) Address :
DIST- DAKSHIN DINAJPUR, PIN- 733125
d) Status of Literacy : One Parent is Literate
11.Bank Details::
Bank Name Branch Savings A/C No. IFSC Code Address
Punjab National Bank
HARIRAMPUR,DK.
HARIRAMPUR 0381201100000022 PUNB0038120
DINAJ PUR

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 Government of West Bengal
Office of the DWO, KOLKATA District
12. a) Name of Institution (mentioning State / UT):GNM SCHOOL OF NURSING, SSKM (S-5527)
Course Type:-
c)Actual date of joining the d)Tentative date of end of
b)Class of Study
class(Academic year 25-26 only) session(Academic year 25-26 only)
Group II (GNM Nursing 3RD YEAR) 2025-01-02 2025-12-31
13.Annual Gross Income (parents / guardians) from all sources : Rs. 72000/-
14.Whether applied for Merit/National Loan Scholarship or any other Stipend / Scholarship : No
15.Whether you in recipient of this scholarship in the previous year : NO

16. Hostel Details

Name & Address of Hostel Date of joining in current Session Charge payable
GNM SCHOOL OF NURSING, SSKM
2025-01-01 144
HOSPITAL (NEW BUILDING HOSTEL)
**For academic session 25-26 only**
(A certificate by Hostel Superintendent and duly countersigned by the Head of the Institution showing exact date of admission to
Hostel & charge payable to be submitted)
17.Identification Proof:Aadhaar Card No. XXXXXXXX5167
I agree to seed my aadhaar details with my bank account.
I undertake that all the statements given above are correct and I shall be liable to penal action if any statement made above is found
false/incorrect.
I hereby declare that I have not applied for any other scholarship/stipend, etc. from any other government sources.

Place ------------------------------
Signature of the Applicant
Date ------------------------------

U T E
T I T I O N
CERTIFICATE OF INSTITUTION

IN IFICA T
The statements made by the applicant in Sl. No. 11,12,14,15,16 are correct to the best of my knowledge. This Institute is affiliated

S
to the ______________________________________ University / Board & is recognized by the Government of India / State
Government of _________________________________. Minimum qualification for admission to the course is a pass in
____________________ Examination.

as per bank passbook.

V R
Certify that,the applicant has not applied for any other scholarship and account number is correct and registered with this applicant

E E
L B I N E
SEAL

W I L N L
_____________________________________

E O Signature of Head of
Institution

DO N Name (in Block Letter) :

Designation :
Address :
State :
Pin Code :
Affiliation/Registration No.

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 Government of West Bengal
Office of the DWO, KOLKATA District

RESIDENTIAL CERTIFICATE

(Should be signed either by a Member of Parliament or Member of a State Legislature, or a Municipal Commissioner / Councillor /
Member of Zilla Parishad / Member,GTA / Savapati of Panchayat Samity or a Government Officer. The issuing authority is
requested to observe due caution as Scholarship is awarded on the basis of this very important Document.)
Certified that the information furnished at point nos. 1 to 11 and 13 overleaf are correct to the best of my knowledge.
Place ------------------------------

Date ------------------------------

SEAL Name (in Block

Letter) :
Designation :
Address :
State :
Pin Code :

DECLARATION OF INCOME

(To be given by the parents/ guardians when the candidate is not employed)
Certified that the gross annual income from all sources in respect of my family is Rs.____________ (Rupees
_______________________________Only) one / two / three of my sons is / are availing such scholarships. I make myself
responsible for the accuracy of the fact & figures furnished.I further undertake that in the event of the particulars given in the
declaration being found false, I shall refund the whole amount of the Scholarship paid to the said Scholarship holder
______________________________ and the Government's decision in this regard shall be final and binding on me.

Place ------------------------------
Signature in full
Date ------------------------------

1. Applicant is to submit the ***computer-generated filled-in application form (duly signed) to the PO CUM DWO.
2. Documents to be submitted along with computer generated application form:
A. 1(One) Copy recent stamp size coloured photograph of the applicant duly attested and pasted on the application.
B. An attested copy of the marksheet/certificate of the last examination passed
C. Copy of the first page of bank passbook(where the account number and bank details is mentioned).
D. Income certificate and proof of Date of Birth(Birth Certificate / Madhyamik Admit Card).
3. The required certificates on the body of the application form are to be provided by the concerned authorities /persons.
4. The application form has to be submitted within 15 days.

Application Date:-2025-05-02

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