GOA SCHOLARS SCHEME Reg.No._____ To: The Director, Directorate of Higher Education, Government of Goa, Junta House, 2nd Lift, 5th Floor, Panaji -Goa. APPLICATION FORM N.B. Please attach pages, if needed A] Personal Profile: Affix a recent passport size photograph 1. Full Name of the student/applicant _______________________________________ 2. Address for correspondence :_______________________________________________ 3. Permanent Address: _______________________________________________________ 4. a) Tel. No.: ________________________ b) email ID :_________________________ c) Mobile __________________________ 5. a) Date of birth :___________________ b) Place of birth :_____________________ (Attach certified photo copies of the Birth & Domicile Certificates) c) Domicile certificate: Enclosed/Not enclosed. B) (1) Academic Profile: Educational qualifications Name of the Institution where studied Name of the Board/University Year of passing Percentage of marks obtained Rank obtained, if any S.S.C.E/Std.X Std.XII (specify the stream): ______________ Degree( specify the stream): _______________ (2) Scholarships / Fellowships received, if any: _______________________________ C] Admission Profile: 1. Course for which admission is confirmed (if so):______________________________ 2. Whether the course is recognized by UGC/AICTE/MCI/DCI/ACI/Govt. of Goa/Govt. of India:_______________________ 3. Name of the Institution where admission is confirmed:________________________ Contd.2 2 4. Full address of the Institution (for admission):______________________________ 5. Quantum of financial support/ Scholarship received/to be received by you for the course, from the Institution/any other source._____________________________ (Attach a certified copy of admission letter/document, as proof) D] Profile of Extra-curricular Activities (including Sports): Course period School Level State Level International level Any other Std X/S.S.C.E Std XII Graduation E)Leadership initiatives, if any:_________________________________________________ F] Essay: An essay of about 1000 words to be enclosed. The essay should be on your strengths/personality/achievements and your vision for future. It should include the reasons why you should be considered for this coveted Scholarship. In the essay, the Committee will look for a realistic assessment of your possible contribution to the development of the State of Goa. Essay: Enclosed/Not enclosed. G] Any other achievements which you feel important to be mentioned. DECLARATION I, Mr/Miss__________________________________,hereby, declare that I have made myself aware of the terms and conditions of the Goa Government Scheme of "GOA SCHOLARS" and I promise to abide by them . I further state that the above information given herein is true to the best of my knowledge and belief. I have not suppressed any relevant information in respect of my application. In the event of any information furnished by me herein, is found to be false or incorrect and/or in the event of any suppression of relevant /necessary data proved against me, I have noted that I would be disqualified from the Scheme and the amount disbursed to me shall become repayable, immediately. Dated: Signature:_______________ Name:___________________ N.B. PLEASE ATTACH CERTIFIED PHOTO COPIES OF ALL THE RELEVANT DOCUMENTS.
