FORMAT OF APPLICATION FOR OFFICIAL USE ONLY 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: 6. Address of the parents. 7. Permanent address: 8. Date of birth (Please enclose certificate) 9. Whether male or female: 10. Nationality: 11. Religion: 12. Details of educational qualifications from matriculation/SSLC/SSC onwards (Please enclose copies of certificates attested by a gazetted officer) Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Telephone no., including mobile number, if any. e-mail ID, if any Name House no. Mohalla/Street City/Town/Village & P.O. District State Pin Code Telephone no., including mobile number, if any. e-mail ID, if any 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 Examination passed University/Board/ Institute/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/course: (ii) Duration of class/course: (iii) Academic year: (iv) Class/course last attended/academic year: (v) Total Marks obtained and percentage in last examination: 14. Details of school/college/institute, including residential ones: (i) Name of the school/college/institute where admitted: (ii) Address of school/college/institute: 15. For renewal of scholarship: 16. Total Annual course fee: Rs....... Name of examination passed Year Marks obtained Full Marks % of marks (Break up of course fee such as tuition fee, library fee, examination fee etc. other than refundable deposits) Sl.No. Item 1 2 3 4 5 6 Total 17. Day Scholar or Hosteller: (i) Whether staying in the hostel run by the school/college/institute (ii) If not and staying as an outstation student as paying guest or in rented accommodation in towns/cities which are not the places their parents resides, then the postal complete address of the landlord of the paying /rented accommodation may be given. Name of landlord Rent per Month Full postal address Pin Code Telephone/Mobile no. of landlord. 18. Details of bank account of student: (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). 19. Annual Income of parents/guardian of the student: Rs._______ (Specimen form of declaration of annual income is given at Appendix to this application form which 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). 20. 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 21. 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 Post-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: Part-II [to be filled up by the Head of the school/college/institute] 22. Details of school/college/institute including residential ones: (i) Name of the school/college/institute where admitted: (ii) Address of school/college/institute: (iii) Telephone no: (iv) Fax no: (v) E-mail address: (vi) If a private institute, is the school/college/institute recognized? If so, the name of authority which has recognized it: 23. Verification/information to be furnished by the Head of school/ college/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/college/institute is correct. (ii) He/she is a hosteller/day scholar of the school/college/institute. or He/She is staying as paying guest/in a rented accommodation at the address given at para 17 as per office records. (i) He/She is a fresher admitted in the school for academic year _________. or He/She has been promoted from _________ to __________ in the academic year ___________. 24. Details of bank account of school/college/institute (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) MI CR code of the Bank___________________ (viii) Mode of Electronic transfer available in the Bank -ECA/RTGS/NEFT/CBS/ code number (if any): 25. For Renewal of scholarship: It is certified that the above mentioned student has passed the____________________________examination for_____________(year) and has obtained ______________% of marks. It is also certified that the student has not changed the course of study and/or the school/college/institute of the study for which the scholarship was originally awarded/has changed the course of study and/or school/college/institute with prior approval of the State Government (please strike out which is not applicable). Signature of Head of the school/college/institute With official seal Date: appendix to the Application Form (Specimen) DECLARATION OF PARENTS'/GUARDIAN'S INCOME 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 "Post-matric scholarship for students belonging to minority communities" could be withdrawn and legal action as deemed fit, may be taken against me or my ward. Signature Date: (Father/Mother/Guardian) Residential Address
