Signature of the issuing Officer RENEWAL APPLICATION FORM Post-Matric Scholarship to Other Backward Classes Students (Sponsored by the Ministry of Social Justice & Empowerment, Government of India) To The Director, Minorities and Other Backward Classes, Photo Government of Manipur, Imphal - 795001. PART - A Sir, I was in receipt of Post-Matric Scholarship for the academic session ...... and I request you for renewal of the same for the academic session .....My particulars are given below: 1. Full Name (in block letters) . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Date of birth (enclose Class X Certificate) . . . . . . . . . . . . . . . . . . . . . ... .. 3. Name of OBC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4. Nationality :. . . . . . . . . . . 5. Religion: . . . . . . . . . . . . . . . ... 6. Permanent address. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. 7. Particulars of father/mother guardian husband : (Strike off whichever are not relevant) (a) Full name (in block letters) :. . . . . . . . . . . . . . . . . . . . . . . . . . (b) Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... (c) Occupation . . . . . . . . . . . . . (d) Total Annual Income : . . . . . . . . ... 8. Were you studying in your school/college institution last year ? . . . . . . . . . . . . . . . ... 9. If NOT, give full name & address of previous institution: . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 10. Classfor which Scholarship was received . . . . . . . . . . . . . . . . . . . . . . ... 11. Did you pass the examination of the class for which scholarship was received ? . . . . . . . . . . ... 12. Amountofscholarship received : . .. .. . .. .. .. .. .. . . . . . .. .. . . 13. Year for which scholarship was received : . . . . . . . . . . . . . . . . . . . . . . ... 14. Particulars of present course of study ;.................... (a) Name of present school, college/institution with full postal address: . . . . . . . . . . . . .. (b) Name of class for which renewalisrequested:. . . . . . . . . . . . . . . . . . . . (c) Class Roll Number : . . . . . . (d) University Registration Number & Year : . . . . . . . .. (e) Regular or correspondence: . . . . . . . . ... (f) Hosteller or Non-hosteller: . . . . . . ... (g) If hosteller, specify (i) Name of hostel: . . . . . . . . . . . . . . . . . . . . . ... (ii) Room number: . . . . . . . . . (iii) Annual Mess:/Boarding Fee: . . . . . . . . DECLARATION I declare and certify that (1) If have not applied/received any scholarship/stipend from any other sources, (2) I am not employed in any govt./semi-govt./private institute/firm, (3) If any statement made by me is found wrong or misrepresented, I undertake to refund in full the scholarship amount paid /drawn by me, (4) In the event of any dispute arising in the award of scholarship, I further give my consent to abide by the decision of the government which will be final and binding upon me, (5) The above statement are true and correct to the best of my knowledge and belief. Date :. . . . . Place: . . . . . (Full signature of the applicant) (FOR OFFICAL USE ONLY) HSLC Roll No. Year Division Board 1. Academic Session : . . . . . .. .. . 2. Duration : . . . . . to . . . . . ... . . . .. 3. Class/Course : . . . .. .. . . . ... 4. Roll No. . . . . ... 5. Year : . . . . . .. . 6. Rate of Maintenance Allowance : Hosteller/Day Scholar = Rs. . . . .x . month = Rs. . . ... . ... 7. Non-refundable fees = Rs. . . . . . . . .. Total (6+7) = Rs. . . . . . . . .. REJECTED/ACCEPTED Reason(s) for rejection : (1) incomplete entries (2) wrong entries (3) high income (4) study break (5) double applications (6) Absence of educational/income/OBC/age/study break/unemployment certificate (7) Absence of applicant's/head of institute's signatures. Signature of Dealing Assistant Signature of Supervisor Countersignature of DDP/PMS PART-B (To be filled in by the Head of the Institution where the applicant is studying) 1. Certified that the applicant is at present studying in . . ... . . . . ... class in this school/college/institution with effect from (date of admission) . . . . . . . . for the academic session . . . . . . . . . .. underadmission number . . . . . . . . .. Class Roll No . . . . . . . . . . . . . . . . . 2. The duration for the whole complete courseis from . . . . . . . . to . . . . . . . .. 3. Likely date, month and year of the annual examination for the class in which the applicant is presently studying: Date . . . . . . . ... . Month . . . . . . . . Year. . . . . . . . . 4. This institution is affiliated to . . . . . . . . . ...University/Board and is recognized by the Government of India/StateGovernment of . . . . . . . . . . . . . . . . . . . . . . . . . 5. Name of the nearest State Bank of India branch where payment is desired . . . . . . . . . . . . Bank Code No. . . . . . . . . . . ... . . 6. The undisbursed amount lying with the institution on account of scholarship, fees etc. will be refunded to the Govt. account of the awarding authority. 7. Further certified that the statements made by the applicant in this application form are correct to the best of my knowledge and I recommended the applicant for award to Post Matric Scholarship for the academic session . . . . . . . . . 8. Particulars of all non-refundable compulsory fees paid by the applicant are as follows : (i) Tuition Fee Rs. . . . . . . . . (ii) Examination Fee Rs. . . . . . . . . . . . (iii) Games Fee Rs. . . . . . . . . (iv) Library Fee Rs . . . . . . . . . . . . . (v) Medical Fee Rs. . . . . . . . . (vi) Any other (to be specified) . . . . . . . . . . Total Rs. . . . . ... . . . . (Rupees. . . . . . . . . . . . . . . . . .) only. Date : Place : (Signature of the Head of Institution with seal) Office Seal: Namein blockletters:. . . .. . . . . . . . .. Full postal address of the institution : . . . . . . . . . . . .. Note : (1) Stamped signature will not be accepted, (2) Full name in block letters of the head of institution is compulsory, (3) Official seal of the head of institution and round seal of the institution are compulsory, (4) The application form will be rejected if declaration is found incomplete or filled in by the applicant or if there are signs of over-writing/erasure. INSTRUCTIONS FOR FILLING UP OF APPLICATION FORM 1. This form is intended for applicants who were in receipt of scholarship in the previous class/year and wish to apply for renewal as they have not completed the course and intend to study the next higher class. Applicant should fill up the form in full correctly and must affix his/her passport size photograph with his/her signature thereon in the space provided in the first page .Enclosed documents will not be returned. The Directorate will not be responsible for any loss of application form/ documents. 2. Applicant is warned that if he/she gives false statements/declarations/documents etc. otherwise obtain scholarship through fraudulent means, he/she will be blacklisted and debarred from scholarship forever under this or any other scholarship scheme. The scholarship amount if already paid will also be recovered. 3. Students having a study break of not more than 3(three) year should furnish a certificate stating the reason of break in his/her academic studies from the present head of the institution. Student having a study break of more than 3 (three) year will not be eligible for this scholarship under any circumstances. 4. Enclose (a) attested Photostat copies of certificates/marks sheets of last examination passed as at 11 part-A, (b) income certificate of father/guardian/husband in original issued by the competent authorities/executive magistrates. (c) Attested copy of OBC Certificate of the candidate issued by competent authorities/executive magistrates, (d) Certificate in support of claim as hosteller as at 14(g), (h) of Part-A (if candidate is hosteller), Verified by a Gazetted Officer, (e) break certificate (where applicable). 5. Incomplete entries, wrong entries, high income, double applications, non-furnishing of the required certificates and documents, and absence of applicant's/head of institution's signature will be rejected. 6. Direct individual submission of the application form will not be accepted. 7. The decision of the Awarding Authority is final.
