GOVERNMENT OF ANDHRA PRADESH Sl.No.

MINORITIES WELFARE DEPARTMENT

APPLICATION FOR ADMISSION INTO GOVERNMENT WELFARE HOSTEL FOR THE YEAR 2007-08

1. Name of the Hostel in which the :

applicant seeks admission

2. Name (in Block letters) :

3. Father / Mother / Guardian’s name :

4. Date of Birth :

5. Native Place :

6. Address :

7. Community :

8. i) Occupation

a) Father :

b) Mother :

c) Guardian :

ii) Total Income of the Parents/Guardian:

9. Social Status of Parents

a) Widow Yes/No :

b)Educational Qualification of the parents

i) Father :

ii) Mother :

Note: Enclose certificate from the competent authority for (a) & (b)

10. Student Status

a) Physically Challenged : Yes ( ) No ( )

b) If yes % of disability :

11. a) Ration Card No. :

b) House hold No: :

12. Name of the school and class now :

Studying

13. Name of the School and Class last :

Studied

14. Distance between Residence and :

Hostel (in KMS)

School Stamp Signature of the HM Signature of the

Applicant

COMMUNITY CERTIFICATE

(Based on the Permanent Community Certificate issued by the M.R.O.)

(In case of Christian only)

Certified that Sri/Smt ...... Son/Daughter of Sri/Smt...... ………….., District ...... ……………., Mandal ……………………………….

Resident of ...... ……. Village/Town and Indian resident and he/she belongs to ...... …..Community.

School Seal Signature of School

Headmaster

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INCOME CERTIFICATE

(Income Delcaration of Father/Mother/Guardian to be certified by the M.R.O)

Certified that Sri/Smt...... ……… Father/Mother/Guardian of Sri/Smt...... the Annual income from all sources Rs...... …… (Rupees ...... only),

Signature of the M.R.O. Signature of Father/Mother/Guardian

Seal

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DECLARATION OF THE STUDENT / FATHER / MOTHER / GUARDIAN

We, that is myself and my son/daughter hereby declare that the particulars furnished above are true to the best of our knowledge and in the event same are proved false we will abide by the action as may be taken by the officer concerned.

Signature of Student Signature of Father/Mother/Guardian

Enclosures with the application:

[ ] 4 passport size photographs

[ ] study / bonafide certificate issued by the school Head Master

[ ] Annual Income Certificate of the parent/guardian issued by MRO

[ ] Xerox copy o the Ration Card

[ ] Physically challenged certificate, if applicable

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HOSTEL WELFARE OFFICER CERTIFICATE

I certify that the above particulars are examined and found that the candidate is eligible/in eligible as per Government rules and regulations.

OFFICE SEAL Signature of H.W.O