GOVERNMENT OF MEGHALAYA [Revised Application Form (Fresh/Renewal) for the Students residing in the notified border village of the State] Application for scholarship to Border Area Students of Meghalaya reading in Schools/Colleges during Note - This application should be submitted to the Director, Higher & Technical Education through the Head of Institutions on or before ____________________ 1. Name of the Student (in block letter) ........................ Age ..... (a) Permanent Village ....................... (b) Name of the Legislative Assembly Constituency where the Student residing ............. (i) Part No. in the Electoral roll ................. Serial No .......... (where the student is 18 years and above) 2. Father's Name ........................................ (a) Name of L.A. Constituency where he/she is the voter .................... (i) Part No. in the Electoral roll ............... (ii) Serial No ........... 3. Mother's Name ...................................... (a) Name of L.A. Constituency where he/she is the voter .................... (i) Part No. in the Electoral roll ............... (ii) Serial No ........... 4. Guardian's Name (where both the parents had expired) ....................... (a) Name of L.A. Constituency where he/she is the voter .................... (i) Part No. in the Electoral roll ............... (ii) Serial No ........... 5. Name of Institution where studying ............................... 6. Class in which studying ....................... 7. Community .................. 8. Name of the last examination taken & passed with year ....................... (a) Division or class obtained .............................. I/We hereby certify that the above information are correct and if any is found to be false and incorrect the Government has got the right to recover the entire amount received by me/us through whatever means it deems proper. I/We hereby declare that I/We have read the regulation of the Scheme and agree to abide by the terms and conditions of the award. Countersignature by Father/Mother/Guardian .............. Date ............ Signature of the applicant ............. Note : - (i) Attested copy each of the certificate/marksheet in respect of all Board/University/ Annual Examination passed be attached. (ii) Incomplete and defective application will be rejected. (iii) Late application received after the last date will not be considered. Annexure - I (Recommendation of the Head of the Institution) I certify to the best of my knowledge that Shri/Smti. _____________________________________________ son/daughter of Shri/Smti. ________________________________ is studying in ___________________________ year/class _______________________ course during the Session ________________________________________ He/She has passed the __________________________________ Examination conducted by the Board/University in the year _______________ in the ___________________ division securing _________________ Position/Rank. The information furnished by him/her are correct to the best of my knowledge and belief and he/she bears good moral character. Name in full _____________________________ Designation and office seal __________________ Annexure - II Permanent Resident Certificate (This certificate is to be signed by the Sirdar or Headman of the Village in which the parent/guardian of the student permanently reside) I certify to the best of my knowledge: - 1. Shri/Smti. ............... Father/Mother of Shri/Smti. ............... is physically residing in the village ............... In .............. District. 2. Shri/Smti. ............... Guardian of Shri/Smti. ................. is physically residing in the village .............. In .............. District and both the parents of the applicant are dead. Signature of Sirdar or Headman ___________________________ Name in full ___________________________________________ Designation and seal ____________________________________ Annexure - III (This certificate is to be signed by the BADO within the jurisdiction the Student and his parents or guardian resides) Certified that to the best of my knowledge and belief the Statement made in the application form are true and that the Residential Certificate is that of the Sirdar or Headman of the Village recognized as border villages) Signature _____________________________________________ Name in full ___________________________________________ Designation and seal ____________________________________ Annexure - IV (For use in the office of the Director of Higher & Technical Education) Amount passed for payment Rs. ______________ (Rupees _______________________________________) only. Check by : - Dealing Assistant Director/Dy. Director Higher & Technical Education Meghalaya, Shillong
