SCHEME OF PRE-MATRIC SCHOLARSHIP FOR STUDENT BELONGING TO THE MINORITY COMMUNITIES FORMAT OF APPLICATION FOR OFFICIAL USE ONLY Sl. No. of application Year Course Whether approved Part - I [To be filled up by applicant.] 1. Full name (in block letters) Surname First Name Middle name 2. Father's name: 3. Mother's name: 4. State/UT of domicile 5. Address for correspondence: Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Telephone no., including mobile no., if any. e-mail ID, if any Affix a self-attested passport size photograph 6. Address of the parents. Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Telephone no., including mobile no., if any. e-mail ID, if any 7. Permanent address: Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Telephone no., including Mobile no., if any. e-mail ID, if any 8. Date of birth (Please enclose certificate) D D M M Y Y Y Y 9. Whether male or female: 10. Nationality: 11. Religion: 12. Details of educational qualifications (Please enclose copies of certificates attested by a gazetted officer) Examination passed School/Institute/Board/Council of Examination Main subjects Year of passing Percentage marks Division/Class/ Grade 13. Details of course for which scholarship is being sought: (i) Name of class: (ii) Duration of class: (iii) Academic year: (iv) Class last attended/academic year: (v) Total Marks obtained and percentage in last examination: (In the case of students of Class I, the income criteria only would be applicable) 14. Details of school/institute, including residential ones: (i) Name of the school/institute where admitted: (ii) Address of school/institute: 15. Total Annual course fee: Rs....... (Break up of fee such as admission fee, tuition fee, library fee, examination fee, etc. other than refundable deposits) Sl.No. Item Annual fee 1 2 3 4 5 6 Total 16. Details of bank account of student: (These details would be required only after sanction of the scholarship and before disbursal of scholarship amount.) (i) Name of the payee (as in the bank accounts) (ii) Name of the Bank (iii) Bank Branch (full address)_____________________________ _________________State___________District__________Pin_________ (iv) Branch Code number (v) Bank Account Number________________________ (in words__________________________________________________) (vi) Type of bank Account_____________Saving/Current (vii) MI CR code of the Bank___________________ (viii) Mode of Electronic transfer available in the Bank - ECA/RTGS/NEFT/CBS/ code number (if any). 17. Annual Income of parents/guardian of the student: Rs._______ (Declaration of annual income is to be given in the prescribed format given below and is to be signed by the parents/guardian of the student and enclosed along with the application. In case parents/guardian are employed, income certificate from the employer be enclosed). 18. Documents enclosed with the application (i) Self-attested passport size photograph with signature. (ii) Attested copies of certificates of educational qualifications as mentioned up in para 12. (iii) Income declaration - affidavit on non-judicial stamp paper for self-employed parents/guardian or income certificate from the employer for employed parents/guardian. (iv) Proof of permanent residence. (v) Minority community declaration - affidavit on non-judicial stamp paper by the student that he/she belongs to any one of the minority communities notified by Central Government 19. Declaration: (i) I hereby declare that the information given above is correct. (ii) I am not availing any other scholarship for this purpose from any other source. (iii) I shall abide by the terms and conditions for sanction of the Pre-matric Scholarship. (iv) I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority in the concerned State Government/Union Territory Administration that the information given by me is false or if I violate the terms and conditions of the scholarship, the scholarship sanctioned to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from such penal action as warranted by law. Date: Signature of the student Place: (Signature/Thump impression of student's parents/guardian for students of Class I to V) Part-II [to be filled up by the Head of the school/institute] 20. Details of school/institute including residential ones: (i) Name of the school/institute where admitted: (ii) Address of school/institute: (iii) Telephone no: (iv) Fax no: (v) E-mail address: (vi) If a private institute, is the school/institute recognized? If so, the name of authority which has recognized it: 21. Verification/information to be furnished by the Head of school/ institute: (i) It is certified that the information filled in the above mentioned columns by Shri/Kumari________________s/o / d/o Shri ________________ who is admitted in________________________________course for the academic session_______________in_____________school/institute is correct. (ii) He/she is a day scholar or hosteller of the school/institute. or He/She is staying in hostel provided by State Government/UT Administration. (i) He/She is a fresher admitted in the school/institute for academic year _________. or He/She has been promoted from _________ to __________ in the academic year ___________. 22. Details of bank account of school/institute/controlling office (For deposit of course fee): (i) Name of the payee (as in the bank accounts) (ii) Name of the Bank (iii) Bank Branch (full address)_____________________________ _____________________State_________District________Pin_________ (iv) Branch Code number (v) Bank Account Number______________ (in words____________________________________________________) (vi) Type of bank Account_____________Saving/Current (vii) MICR code of the Bank___________________ (viii) Mode of Electronic transfer available in the Bank - ECA/RTGS/NEFT/CBS/ code number (if any);- Signature of Head of the school/college/institute Date: With official seal Place: DECLARATION OF PARENTS'/GUARDIAN'S INCOME (Specimen) (on non-judicial stamp paper of Rs. 10/-) I..........................(Parents/Guardian) of ........... ..........(Name of Student) who is studying in ................ hereby declare that my annual income from all sources is Rs.... (in figures) Rupees............. . . . . ........only (in words). If any stage, it is found that the information given by me is false/not true, all benefits given to the student under the scheme of "Pre-matric scholarship for students belonging to the minority communities" could be withdrawn and legal action as deemed fit, may be taken against me or my ward. Date: Signature (Father/Mother/Guardian) Residential Address
