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Government of West Bengal
Office of the DWO, COOCHBIHAR District
APPLICATION FOR POST MATRIC SCHOLARSHIP TO SC/ST / OBC STUDENTS (AY: 2023-24)
NEW/RENEWAL Application Serial No. : WB010214531598
1. Full Name of Applicant Shri/Kumari : SAGAR BARMAN

2. Father's/Husband's Name : DINESH BARMAN.
4. Date of
3. Gender : Male : 2003-04-26
Birth
5. Nationality : INDIAN
7. Telephone
6. Aadhar No : XXXXXXXX4249 : 8101153051
No.
b). Marital
a). E-mail Address : : Un-married
Status
8. a) Caste : SC b) Sub-Caste : RAJBANSHI

c) Caste Certificate No : WB0302SC201802192 d) Dated : 2018-09-25
e) Issuing Authority,
: SDO Dinhata, COOCHBIHAR District
District
f) Religion : Hindu
9. a)State to which applicant actually belongs : West Bengal
b) Permanent Address : SEORAGURI
P.O. P.S. District PIN
Mansab Seoraguri BO SAHEBGANJ COOCHBIHAR 736134
c) Present Address : SEORAGURI
P.O. P.S. District PIN
Mansab Seoraguri BO SAHEBGANJ COOCHBIHAR 736134
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 : DINESH BARMAN
b) Occupation (if employed, give income certificate from the
: FARMER
Employer)
c) Address : SEORAGURI ,DINHATA ,COB
d) Status of Literacy : Both Parents are Literate
11.Bank Details::
Bank Name Branch Savings A/C No. IFSC Code Address
P.O.SALMARA VIA
Bank of Baroda DEWA
SALMARA WEST
23468100000737 BARB0SALMAR NHAT,DIST.COOCH
BENGAL
BEHA R,WEST
BENGAL 736 13
Page 1
12. a) Name of Institution (mentioning State / UT):Cooch Behar College (C45321)
Course Type:-
c)Actual date of joining the d)Tentative date of end of
b)Class of Study
class(Academic year 23-24 only) session(Academic year 23-24 only)
Group II (B.B.A 3rd year) 2023-11-19 2024-10-31
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 : 8420
16. Hostel Details

Name & Address of Hostel Date of joining in current Session Charge payable
**For academic session 23-24 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. XXXXXXXX4249
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.
Page 2
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:-2024-01-19
Page 3

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Government of West Bengal

Office of the DWO, COOCHBIHAR District

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

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

16. Hostel Details

For academic session 23-24 only

SEAL Name (in Block

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