Recommended for grant of Pension of Rs. as per provisions of the Scheme, "Sports Fund for Pension to Meritorious Sportspersons", Ministry of Youth Affairs & Sports, Govt. of India Signature of the Recommending Authority (president or Secretary of the concerned National Sports Federation) or (Deputy Secretary/Director, Sports Department on behalf of the State Government) (To be furnished in a separate sheet attached to the Application) Name Specimen signature of the applicant (Dulyattested)* 1. 2. 3. *The signatures of the applicant are to be duly attested by a Gazetted Officer whose name, designation and full address should be clearly mentioned. Annexure IV APPLICATION FORM FOR SPORTS SCHOLARSHIP SCHEME :- ,.- -- (Please till in block letters only and tick whichever is applicable) Scholarship applied for i) State level Sports talent Scholarship (Category-!) ii) National level Sports Talent Scholarship (Category-ll) iii) Scholarship for College/University students (Category-III) iv) Senior Women Sports Scholarship v) Scholarship for Women for Diploma in Sports Coaching vi) Scholarship for Women for doing M.Phil/Ph.D. in Physical Education. 2. Name (Please give full name) 3 Father/Guardian/Husband's name 4. Present address (Village/Town post office/DistrictlState/Pincode 5. Date of Birth (in Christian era) (in figure and words) DD/MM/year 6. Age (as on the first day of competition) 7. Whether belong to SC/ST /OBC 8. Class and name of School/College attending 9, Details of sports events qualifying for the scholarship a) Championship/Tournament Category (age group) S tate/N ati onal/Jntemati onal b) Organized by (Name of the Organization) Date of competition From Venue: City. District Sports Discipline Sports events (teams/Individuals) Rank Performance in case of measurable individual event (attach copies of achievement certificate awarded) c) d) e) f) g) h) to State 9, Details of scholarship for sports received from all other sources, Certificate Certified that infonuation given above are true to the best of my knowledge and belief. That I agree to abide by the tenus and conditions of the scheme. In the event of any infonuation given above found to be false or incorrect, I shall be liable to refund the amount received and such other action as provided under the law. (Full signature of the applicant) Certificate by PrinciRal/Head Master/President or Honv. Secretary of National Sport F ederatiQIi/Director Phvsical Education/Director of Sports University. Certified that all the infomlation given above and particularly achievement of the sports person are true as per the official records. {Full signature. Name and official seal) Place and date ~ In case of scholarship for Diploma/M.Phil/Ph.D. details of educational performance starting from 10 + standard and a resume of the work to be done should be done annexed. Annexure-I Sports Fund for Pension to Meritorious Sportspersons Application Foml for Pension (To be submitted induplicate) 1. Name of the applicant (in capital letters) 2. Father/Husband's Name 3. Postal Address (in capital letters) 4. Date ofbirth (Attach documentary proof) 5. Discipline of sports and the Event in which participated 6, Achievement a) Olympics Games b) World Cups/World Champ. c) Asian/Commonwealth Games d) Para-Olympics Undertakin!! I do hereby solemnly declare and affinn that the particulars mentioned above are correct. I also undertake that income tax liability, if any, accruing as a consequence of the above pension payments will be my sole responsibility and accountability. I also undertake that I have retired from the active sports career Date : (Signature of the Applicant)
