Government of West Bengal

Office of the PO cum DWO, UTTAR DINAJPUR District

APPLICATION FOR POST MATRIC SCHOLARSHIP TO SC/ST / OBC STUDENTS (AY: 2024-25)
NEW/RENEWAL Application Serial No. : WB010215593437

1. Full Name of Applicant Shri/Kumari : POPI BARMAN

2. Father's/Husband's Name : CHITTYARANJAN BARMAN.
4. Date of
3. Gender : Female : 26-01-2000
Birth
5. Nationality : INDIAN
7. Telephone
6. Aadhar No : XXXXXXXX4723 : 8509438398
No.

b). Marital
a). E-mail Address : POPIBARMAN002@[Link] : Un-married
Status

8. a) Caste : SC b) Sub-Caste : RAJBANSHI

c) Caste Certificate No : WB0104SC201201882 d) Dated : 2012-06-26
e) Issuing Authority,
: SDO Siliguri, DARJEELING GTA District
District
f) Religion : Hindu
9. a)State to which applicant actually belongs : West Bengal
b) Permanent Address : VILL: DHUKURIA, P.O: NEW CHAMTA, P.S: MATIGARA, DIST: DARJEELING PIN-734009
P.O. P.S. District PIN
New Chumta BO MATIGARA DARJEELING SILIGURI 734009
c) Present Address : VILL: DHUKURIA, P.O: NEW CHAMTA, P.S: MATIGARA, DIST: DARJEELING PIN-734009
P.O. P.S. District PIN
New Chumta BO MATIGARA DARJEELING SILIGURI 734009
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 FATHER who supports in applicant’s studies
a) Name : CHITTYARANJAN BARMAN
b) Occupation (if employed, give income certificate from the
: LABOUR
Employer)
VILL: DHUKURIA, P.O: NEW CHAMTA, P.S:
c) Address :
MATIGARA, DIST: DARJEELING, PIN: 734009
d) Status of Literacy : Both Parents are Literate
[Link] Details::
Bank Name Branch Savings A/C No. IFSC Code Address
NH31C ASSAM ROAD
Indusind Bank BAR OBISHA
BAROBISHA 100212414890 INDB0000728 DAKSHIN RAMPU R
REGULATOR
MARKET A

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 Government of West Bengal
Office of the PO cum DWO, UTTAR DINAJPUR District
12. a) Name of Institution (mentioning State / UT):S B SCHOOL OF NURSING (S-20155)
Course Type:-
c)Actual date of joining the d)Tentative date of end of
b)Class of Study
class(Academic year 24-25 only) session(Academic year 24-25 only)
Group II (G.N.M(Nursing) 3rd y) 2025-01-06 2025-12-29
[Link] Gross Income (parents / guardians) from all sources : Rs. 84000/-
[Link] applied for Merit/National Loan Scholarship or any other Stipend / Scholarship : No
[Link] 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

**For academic session 24-25 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)
[Link] Proof:Aadhaar Card No. XXXXXXXX4723
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
CERTIFICATE OF INSTITUTION

I T I O N
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

T
S
IN IFICA T
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.
Certify that,the applicant has not applied for any other scholarship and account number is correct and registered with this applicant
as per bank passbook.

V ER E
L B I N E
SEAL

W I L N L
O
_____________________________________ Signature of Head of

N E Institution
Name (in Block Letter) :

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

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 Government of West Bengal
Office of the PO cum DWO, UTTAR DINAJPUR 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 Raigunj Block Development
Office. .
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:-2025-04-26

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