MERIT-CUM-MEANS BASED SCHOLARSHIP FOR STUDENTS BELONGING TO MINORITY COMMUNITIES FORMAT OF APPLICATION FOR OFFICIAL USE ONLY Sl. No. of application Year Course Whether approved Affix a self attested passport size photograph 2. Full name: (In block letters.) Surname First Name Middle Name 3. Father's name / husband's name: 4. Mother's Name: 5. Domicile State / UT (State / UT which the student belongs to) 6. Address for correspondence: House No. Mohalla/Street City/Town/Village & P.O. District State Pin Code 7. Permanent address (please enclose residential certificate from concerned state government authority): 8. Date of birth [ please enclose certificate ] 9. Whether male or female : 10. Religion: 11. Nationality : 12. Details of educational qualifications from matriculation/SSLC/SSC onwards (Please enclose certificates attested by a gazetted officer) 13. Details of course for which scholarship is being sought: (i) Name of the technical/professional course: (ii) Duration of course: (iii) Academic year: 14. Basis of admission in professional/technical course (whether on the basis of qualifying competitive examination or on other grounds. Please give details ): 15. Details of college/institution (i) Name of the college / institution where admitted: (ii) Address of college / institution: House No. Mohalla/Street City/Town/Village & P.O. District State Pin Code D D M M Y Y Y Y Examination Passed University/Board/Institution/ Council of Examination Main subjects Year of passing Percentage marks Division/class/ Grade (iii) Telephone no: (iv) Fax no: (v) E mail address: (vi) Is the college/institution recognized. If so, then name of authority which has recognized the institution: (vii) To which university is it affiliated / does it have deemed university status: 16. For renewal of scholarship: 17. Total Annual course fee: Rs............. (Break up of course fee such as tuition fee, library fee, examination fee etc. other than refundable deposits) 18. Details of bank account of student: (x) Name of the payee (as in the bank accounts) (xi) 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 (vi) MICR code of the Bank___________________________________________________ (vii) Mode of Electronic transfer available in the bank ECA/RTCS/NEFT/CBS/code number ( if any): 19. Annual Income of parent/guardian of the student : Rs__________________________ Name of examination Passed Year Marks obtained Full marks % of marks Sl. No Item Annual fee 1. 2. 3. 4. 5. 6. Total (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) One copy of passport size photograph with signature. (v) Attested copies of certificate of educational qualifications as filled up in para 11. (iii) Income declaration - affidavit on non - judicial stamp paper and Income certificate from the employer. (iv) Proof of permanent residence. (v) Receipt in acknowledgement of scholarship in the previous year duly countersigned by the head of the institution. 21. Declaration: (i) I hereby declared that the information given above is correct. (ii) I am not availing any other Scholarship for this purpose from any other sources. (iii) I shall abide by the terms and conditions for sanction of the merit-cum-means based Scholarship. (iv) I undertake that if, at any stage, it is found to the satisfaction of the sanctioning authority in the Ministry of Minority Affairs that the information given by me is false or if I violate the terms and condition of the scholarship, the scholarship sanction to me, may be cancelled and the entire amount of scholarship will be refunded by me or recovered from me, apart from liability for such penal action as warranted by law. Date : Place: Signature of the student 22. Verification/information to be furnished by the Head of Institution / college: It is certified that the information filed in the above mentioned columns by Shri / Smt / Kumari ___________________________________S/O, D/O, W/O Shri________________ who is admitted in__________________________course for the academic session______________in _____________________________ college is correct. He / She is a hosteller / day scholar of college. 23. Detail of bank account of institution [ For deposit 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______________________________________________________ (iv) Bank Account number_______________in words_____________________________) (vi) Type of Bank Account____________________________Saving/Current (v) MICR code of the Bank___________________________________________________ (vi) Mode of Electronic transfer available in the Bank ECA/RTCS/NEFT/CBS/code number ( if any): Date: Place: Signature of Head of Institutution / college With official seal Annexure DECLARATION OF FAMILY INCOME I .............................(Father / Mother / Guardian ) of .......................................(Name of Student) who is studying in................................... ......................hereby declare that my annual income from all sources is Rs...................in word........................................ If at 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 Merit-cum-Means based scholarship to the student belonging to minority communities" could be with drawn and legal action as deemed fit, may be taken against me or m ward. Date: Signature (Father/Mother/Guardian) Residential Address [ This is a draft format which the State government / UT administration may modify / amend to suit legal requirements.]
