GOVERNMENT OF GUJARAT Submit Date

Umbrella Scheme for Education of ST Students Post-Matric Appllcation No:

Scholarship 222300000001362481
Fresh Application

Student Basic Details

Name of Student:
GAYAN VIRAJKUMAR
Name of Student NILESHBHAI
(As per Aadhar) : VIRAJKUMAR NILESHBHAI GAYAN
Mother's Name : LILABEN
Date of Birth :
01/02/2004
Category: ST(MJAA *t ua Gender: Male
Caste: Kukna(g 821) Religion :Hindu
Aadhaar Status Verified:
Annual Income of Yes(12/10/2022 09:36:00)
Mobile Number : Parents/Guardian/Husband (Rs): 62000
Habitation Type: Rural
9081090240
Aadhar No : 42xxxxx8500 E-mail Address :
Is Orphan: NO sahilgayan22@gmail.com
Parent/Guardian occupation: Agriculture(cl)
Marital Status: Unmarried Day Scholar Hosteller
Hostel Type:
Day Scholar
Current Address:
Stnte
Gujarat Permanant Address:
District Navsari State Gujarat
Taluka District
Khergam Navsari

Village Panikhadak Taluka Khergam

PinCode 396060 Village Panikhadak
Address:AT PO PANIKHADAK PinCode 396060
NAYAK FALIYU
KHERGAM DI NAVSARI GUJARAT TA
Address:AT PO PANIKHADAK
396060 NAYAK FALIYU
KHERGAM DI NAVSARI GUJARAT TA
Student Bank Account Detail/Aadhar Bank Detail 396060

I voluntarily give my consent to use my Aadhaar details.

Aadhar Number : 42xxxxxx8500
Bank name:-
Mandate Date: Status
I am giving
my consent for payment of
Account No : 30xxxxxx2700
scholarship amount in my bank account, linked with Aadhar.

Student Name(As per Bank Name): VIRAJKUMAR NILESHBHAI

IFSC Code: BARBOBGGBXX
GAYAN
Name of Bank : BARODA GU.JARAT GRAMIN BANK
Branch Name & Address: ACHHAWANI
Ihereby accept that
I.Details provided by correct to best
me are
of my knowledge
2.Shall not makeany claims if amount is transferred to a wrongaccount due to incorrect details provided by me
3.Shall refund the amount transferred to someone clse'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: Engincoring & Technology
Present Course/Class/Trade Name : B.E. (Bachelor of Engincering)

Present Course/Class/Trade Year: 2ND YEAR(3rd Semester/4th Semester)

Enrollment No: 210190106064
Studying in: Gujarat
Print Date :12/10/2022
222300000001362481
Page 1 of3
Courtesy: National Informatlcs Centre, Gujarat
 Present Institute Present Institute: GOVERNMENT ENGINEERING COLLEGE,
District: Valsad
VALSAD 019
Admission Type: Regular Present Branch Course: Civil Engincering
Scat(Government Quota)

Present Class Start Date: 12-Scp-2022 Present Course Completion Date: 31-May-2023
Fees
Amount
Admission Fees (Rs)
Tution Fees (Rs)
1500
Misc.Fee(NonRefundable
Exam Fees(Rs)
Fees) 1650
1575
Total (Rs)
4725
Previous stream :B.E. (Bachclor of Engincering)
Previous Passing Year : 2022 Previous Class/Course : 1ST YEAR(Ist Semester/2nd Semester)
Educational Break No Previous (%): 33.00
Are You No. Of. Year in Brealk:
Employed in any
Organization/Establishment with leave without pay? #Not Applicable
Previous Education Detail
Course/Class/Trade Type Course/Class/Trade Name
9th Std/10th Std Branch Name
10TH Seat No Passing Year Percentage
I 1th Std/12 Std GENERAL B5427408
12TH 2019 71.83
Engincering &Technology SCIENCE B120109
B.E. 2021 62.83
(Bachelor of Engineering) SEM 1 21019010
2022 33
Disablity Detail 6064

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:

I Caste Ccrtificate From the Competent Authoritics

2 First Page Of Bank PassBook/Cancclled Cheque

3 Fee Receipt of Current Course Ycar

4 Sclf Attested Certificate of Previous academic markshect

5 Income Certificate From the Concermed Authoriscd

Authority/Persons
I have read all above terms and conditions and understand them fülly, 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: 12/10/2022

Place: Signature of the applicant

It is certified that the information filled in the above mentioned fields by the students are coect to the best of my knowledge and
all the Documents has been çhecked.
studies detained or accepts any other
applicant leaves institution or otherwise discontinues the
or
Tt is also certified that in case the
to the said authority
regular scholarships/stipend/ fellowship the fact will be immediately reported
Central/State government rules and the student is
Certified that the student is eligible for scholarship amount subject to
recommended for sanction of scholarship.

Print Date :12/10/2022

222300000001362481
Page 2 of 3
Courtesy : National Informatics Centre, Gujarat
This 1s to
certify that
-2023.If student willstudent has regularly attended classes and maintained
irregular, than we will immediately minimum attendance
reported to the said authory
The actual
School/College/University year began on
and will be ended on

Signature orHead Of TheSchool/College/Institute/University With Official Seal

Place
*Note: Stamp Signature will not be accepted

Date: