September 28, 2014 02:27:52 PM
Government of Karnataka
Department of Backward Classes Welfare
Student Appl!aton !um "erf!aton #eport for
$ee %on!e&&on Fresh 2014-15
1. Application No: 2014 0102 6244 2. Application Date: 27-09-2014 3. Caste Category / Caste: CAT-IIIB / Lingayath/Veerashiva-Veerashaiva Panchamasai!"#$%-1-!&'''
4. Student Name : (AVI)*+A( , + 5. Gender : +ae
!a". #at$er Name : ",A($ABA"AVA(A- , + !%". &ot$er Name : .A$.A++A , +
'. Address ( &o%ile No : .A$/I$A.A(A 0Beary 0 Beary !Cmc' - 1n%#21 0B2LLA(3 4 9567776946
). SS*C +, No : 20040106457
-. .ass /ear: 2004-)arnata8a
""LC B%ar9
10. Date o1 2irt$: 06-06-1977
11.#amily Annual 3ncome !in 4s.": 12000 12. 4ation Card :
[Link] Details!college Nature" : -A1A,A(LAL $2,(* $ATI:$AL C:LL2.2 :; 2$.I$2(I$. 0 "him%ga0"him%ga 0 !Private C%ege' 0Visvesvaraya
Techn%%gica *niversity !VT*'0 Bega<m
14. Course Name /Course /ear /Duration o1 Course : +T2C, !/2C"' / I 3r / 23rs
15. College Admission No / Admission Date!o1 t$is year": 1471007051
/ 14-09-2014
1'( )&tan!e *n Km&(+ : 210
1'. Sc$olars$ip ,ype : /ay "ch%ar 1). Sc$olars$ip Applied 1or: 1#;ee C%ncessi%n
1-. 2an5 Name / 3#SC Code: "TAT2 BA$) :; I$/IA
/"BI$0000717
20. 2an5 A/c No : 66690260776
I#/ecarati%n
3 $ere%y certi1y t$at t$at a%o6e in1ormation 1urnis$ed is true. 3 $a6e not a6ailed any ot$er sc$olars$ip 1or t$is purpose 1rom any ot$er sources. 3
s$all a%ide %y t$e terms and conditions o1 t$e sanction o1 t$e sc$olars$ip. 31 any discrepancies are 1ound later7 3 $ere%y a%ide 1or re1und o1 t$e
sc$olars$ip amounts claimedand also am lia%le 1or action %y t$e Department. .
/ate =
"ignat<re %> the "t<9ent
II#Veri>icati%n (e?%rt %> C%ege Princi?a
,$is is to certi1y t$at t$e in1ormation 1urnis$ed a%o6e is 6eri1ied 8it$ t$e records and 1ound to %e correct. +e / S$e is a %ona1ide student o1 our
college studying in &,9C+ !D9CS" / 3 /r !Course ( Course /ear" during 2014:15 .
/ate =
"ignat<re %> the Princi?a
!1ith C%ege "ea'
III#Veri>icati%n (e?%rt %> Veri>icati%n :>>icer/
3 $a6e 6eri1ied t$e contents o1 sc$olars$ip ;resh application 8it$ re1erence to t$e college records and original certi1icates7 p$ysically identi1ied
t$e student 6eri1ied t$e 1ollo8ing certi1icates
Caste : ,e& -o Income: ,e& -o SSC: ,e& -o !C: ,e& -o "at#on Card: ,e& -o
$ther Deta#ls%Cert#f#cates #f an&:
3 recommend 1or sanction o1 :
#ee Concession
3 do not recommend t$e sanction o1 sc$olars$ip 1or t$e 1ollo8ing reasons. !.lease speci1y"
3 $a6e p$ysically 6eri1ied t$e SS*C Certi1icate in person
/ate = "ignat<re %> the Veri>icati%n :>>icer
Prnt . Appl!aton /ttp:00karepa&&(!11(1ov(n0Prnt(do2t3pe4app5apno420140102'2445fre(((
1 of 1 2800602014 2:71 PM