POST-MATRIC SCHOLARSHIP FOR STUDENTS BELONGING TO MINORITY COMMUNITIES FORMAT OF APPLICATION FOR OFFICE USE ONLY Sl. No. of application Year Course Whether approved Part -1 [ To be filled by application ] 1. Full name: (In block letters.) Affix a self attested passport size photograph Surname First Name Middle Name 2. Father's name: 3. Mother's Name: 4. State / UT of domicile: 5. Address for correspondence: 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 6. Address of the parents 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 7. Permanent address: 8. Date of birth [ please enclose certificate ] 9. Whether male or female : 10. Nationality : 11. Religion: 12. Detail of educational qualification from matriculation / SSLC/SSC onwards (please enclose copies of certificates attested by a gazetted officer.) 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 mark obtained and percentage in last examination: (vi) Exact date of which the application joined the course: 14. Detail of the school/institute, including residential ones: (i) Name of school/college/institute where admitted: (ii) Address of school/college/institute: 15. Total Annual course fee: Rs. ............. 16. 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 town/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 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 D D M M Y Y Y Y Examination Passed University/Board/Institute/ Council of Examination Main subject Year of passing Percentage marks Division/class/ Grade (Break up of course fee such as tuition fee, examination fee etc, other than refundable deposits) Sl. No Item Annual fee 1. 2. 3. 4. 5. 6. Total Name of the land lord Rent per month Full postal address Pin code Telephone/Mobile no. of a landlord 17. 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) MICR code of the Bank_____________________________________________________ (viii) Mode of Electronic transfer available in the bank:_________________________________ (ix) ECA/RTCS/NEFT/CBS/code number ( if any): 17. Annual Income of Parent/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). 18. Documents enclosed with the application. (i) Self attested passport size photograph with signature. (ii) Attested copies of certificate 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. (vi) If the student has applied any other scholarship/Stipend. He/She should opt only One scholarship. An option Certificate should be obtained from the Head of the Institution. 19. 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 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 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 such penalty action as warranted by law. Date : Place: Part - II [to be filled by the Head of the school/college/institute] 20. Detail 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) Email address: Signature of the student (vi) If a private institute, is the school/college/institute recognized? If so, the name of authority which has recognized it: 21. Verification/information to be furnished by the Head of school/college/Institute: (i) It is certified that the information filed in the above mentioned columns by Shri / Kumari ___________________________________S/o / D/o of 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 paying guest / in a rented accommodation at the address given at Para 16 as per office records. (iv) He / She is a fresh admitted in the school / college for academic year__________________ Or He / She has been promoted from _________to________in the academic year__________ 22. Detail of bank account of school / college /college /institute [ 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________________________________________________________ (v) Bank account Number: ______________________________________________________ (In words________________________________________________________________) (vi) Type of bank Account___________________________________Saving/Current. (vii) MICR code of the Bank_____________________________________________________ (viii) Mode of Electronic transfer available in the Bank: ECA/RTGS/NEFT/CBS/code number (if any) Date: Place: Signature of Head of the School/College/Institute With official seal
