APPLICATION - 3 (SSY)
Proforma - A-I

SHIKSHA SAHAYOG YOJANA
(for the holders of Janashree Bima Yojana Scheme)

PART A : (to be completed by beneficiary)

  1.   Name of the beneficiary (member of JBY) in BLOCK LETTERS  
  2.   Address :





 
  3.   Name of Father/Husband :  
  4.   Registration No. of the Scheme (JBY) :  
  5.   Name of the Nodal Agency through which the beneficiary became member.  
  6.   Particulars of children(s)
Sr.
No.		 Name of the child Age Class in which
studying 		Name & Address of the School.
1.

       
2.

       
  7.   Whether Certificates indicated in opposite col. are enclosed in respect of each student:
Yes/No		 1) Bonafide Certificate from the Head of the School, where studying.
2) Attested copy of the mark sheet for the previous year

I hereby declare that all the above particulars are true and correct in every respect.


Place: _________________  
Date: __________________ ( Signature of Member )


PART B : (to be completed by the Nodal Agency)

Certified that the above information is correct in every respect. Applicant named above is a bonafide member of the JBY Scheme and his membership (Regn. No. _________________) is in operation during the relevant period.



Place: _________________ __________________________________
Date: __________________ Signature & Seal of the R.O. / PSC