GOVERNMENT OF GUJARAT Submit Date : 15/11/2022

Application No:
PM -YASASVI Post Matric Scholarship for OBC, EBC and DNT 222300000002048926
Students
Fresh Application

Student Basic Details

Name of Student : Patel Raj Kantilal
Name of Student (As per Aadhar) : Raj Kantilal Patel
Mother's Name : jyotshnaben
Date of Birth : 25/01/2001 Gender : Male
Category : EBC(8iTD^ŽSpXJhSaF½  Religion :Hindu
Caste :
Aadhaar Status Verified: Yes(12/11/2022 22:14:00)

Annual Income of Parents/Guardian/Husband (Rs): 90000 Habitation Type: Urban

Mobile Number : 7622827236 E-mail Address : [email protected]
Aadhar No : 24xxxxxx1788 Parent/Guardian occupation: Shopkeeper(ȳkDhWUh^
Is Orphan: NO Day Scholar / Hosteller : Day Scholar
Marital Status : Unmarried Hostel Type:

Current Address: Permanant Address:

State Gujarat State Gujarat

District Patan District Patan

Taluka Patan Taluka Patan

Village Village
PinCode 384265 PinCode 384265

Address:Zinipol near Lal darwaja Address:Zinipol near Lal darwaja

Student Bank Account Detail/Aadhar Bank Detail

I voluntarily give my consent to use my Aadhaar details.
Aadhar Number : 24xxxxxx1788 Bank name : -
NPCI Date : - NPCI Status :
I am giving my consent for payment of scholarship amount in my bank account, linked with Aadhar.
Account No : 50xxxxxx0723 IFSC Code : HDFC0005026
Student Name(As per Bank Name): Raj Kantilal Patel

Name of Bank : HDFC BANK LTD

Branch Name & Address : UNIVERCITY ROAD PATAN

I hereby accept that
1.Details provided by me are correct to best of my knowledge
2.Shall not make any claims if amount is transferred to a wrong account due to incorrect details provided by me
3.Shall refund the amount transferred to someone else¶s account due to incorrect details provided by me
4.I will refund the excess amount credited to my account, if any.

Student Academic Details

Present Course/Class/Trade Type: Information Technology

Present Course/Class/Trade Name : MCA (Master of Computer Application)

Present Course/Class/Trade Year : 1ST YEAR(1st Semester/2nd Semester)

Studying in : Gujarat Enrollment No:

Present Institute District : Patan Present Institute : Hemchandracharya North Gujart University, Patan

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 Admission Type : Regular Paid Seat (Self Finance) Present Branch Course : -

Enter Your Research/Thesis Subject :

Present Class Start Date : 14-Jul-2022 Present Course Completion Date : 29-Apr-2023

Fees Amount
Admission Fees (Rs) 0
Tution Fees (Rs) 30000
Misc.Fee(NonRefundable Fees) 0
Exam Fees(Rs) 3400

Total (Rs) 33400

Educational Break : No No. Of. Year in Break :

Previous Education Detail

Course/Class/Trade Type Course/Class/Trade Name Branch Name Seat No Passing Year Percentage
9th Std/10th Std 10TH GSEB A7314173 2017 66.66

11th Std/12 Std 12TH GSHSEB B269061 2019 56

Science B.Sc Bachelor Of Science HNGU 01697 2022 67.9

Disablity Detail
Is Disability : No Type of Disability : -

Percentage of disability : - Required Guide/Coaching Guide: No

Guide Name: -
Guide Address: -

List of documents which you have attached :

1 Caste Certificate From the Competent Authorities

2 First Page Of Bank PassBook/Cancelled Cheque

3 Fee Receipt of Current Course Year

4 Self Attested Certificate of Previous academic marksheet

5 Income Certificate (Competent Authority)(Form no.16 required For Govt. Employee)

6 School Leaving Certificate (If Any)

7 Identity Card (College/School)

I have read all above terms and conditions and understand them fully, I hereby declared that here I am submitting only one
application for scholarship and I haven¶t received any other scholarship/stipend or fellowship in this current session under any other
central/state government scheme. I further state that all information furnished by me is correct to my knowledge in case of any the
false information or suppression of necessary data proved in my application is liable to get cancelled at any stage of the scholarship
process and the entire amount of scholarship will be refunded by me or recovered from me. Government decision shall be final and
binding on me.

Date : 16/10/2023
Verify Mobile Number : Yes 26/11/2022
Place : Signature of the applicant
It is certified that the information filled in the above mentioned fields by the students are correct to the best of my knowledge and
all the Documents has been checked.

It is also certified that in case the applicant leaves institution or otherwise discontinues the studies or detained or accepts any other
regular scholarships/stipend/ fellowship the fact will be immediately reported to the said authority

Certified that the student is eligible for scholarship amount subject to Central/State government rules and the student is
recommended for sanction of scholarship.

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This is to certify that student has regularly attended classes and maintained minimum attendance criteria till date for the A.Y. 2022
-2023. If student will irregular, than we will immediately reported to the said authority.

The actual School/College/University year began on __________________ and will be ended on _____________________

Signature Of Head Of The School/College/Institute/University With Official Seal

Place :
*Note : Stamp Signature will not be accepted

Date :

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