FRESH APPLICATION FORM FOR POST MATRIC SCHOLARSHIP TO SCHEDULED TRIBES/SCHEDULED CASTES STUDENTS OF MEGHALAYA DURING 200__ 200__. To, The Director of Higher & Technical Education Meghalaya, Shillong Passport Size Photograph Through the (Head of Institution) ___________________________ with his/her signature ______________________________________________________ thereon PART A (TO BE FILLED BY THE APPLICANTS) 1. Name of the applicant (in block letter) ________________________________________________ 2. Date of Birth _______________________________ 3. Caste/Tribe ___________________________ Community _______________________________ Religion ________________________________ 4. Permanent Address in full _________________________________________________________ (i) Course of study for which the Scholarship is now desired (ii) Authority who will award Degree/Diploma Certificate after completion of the Course (iii)Subject taken for course of study _________________________________________________ 5. Whether the candidate was in receipt of Scholarship under this scheme or any Scheme in proceeding year 2000 - ___ Yes/No If yes, please indicate: - (a) Name of the Scholarship Scheme _________________________________________________ (b) Course of study for which Scholarship was awarded _________________________________ (c) Class, Year the Scholarship enjoyed last __________________________________________ Name of Institution in which the Scholarship was awarded ____________________________ (d) Sanctioning No. and date ______________________________________________________ Allotted No. ________________________ 6. (i) If the applicant pass the last University/Board/Annual Examination earlier than proceeding year, particular of how he/she occupied himself/herself after passing that examination. What active during gap period given in details _______________________________________ That activities during gap period should be given in details ______________________________ (ii) State if you have change Course of study without completion of the course of study. (iii) Whether you have failed in the promotion examination Yes/No. if Yes indicate the number of time __________________________________________________________ 7. Whether residing in the hostel of the Institute or in any approved Hostel ___________________ _____________________________________________________ Yes/no (i) Father's name in full __________________________________________________________ (ii) Mother's name in full _________________________________________________________ (iii)Guardian's name in full (if both parents have died) __________________________________ (iv)Name of Children of the parents applying for Scholarship:- Name Surname Male/Female Year, Class and Institution Courses 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________ I/we hereby declare that I/We have read the regulations of the scheme and agree to abide by the terms and conditions of the award. I/We certify that the statement in the application are correct, and, if any of them is found to be false and incorrect by the authority whose decision will be final and binding on me/us. I/We undertake to refund to the said authority or demand the entire amount of Scholarship received by me/us or overpaid to me/us failing which the said authority may recover the amount from me/us through whatever means it deems proper. (i) Signature of the applicant ________________________________________ (ii) (a) Signature/Left/Right hand thumb impression of the parents/ guardian_____________________________ (b) Full name in Block letters ____________________________________ (c) Relation to Student _________________________________________ INCOME CERTIFICATE Certified that to the best of my knowledge the annual income from all sources in preceding year ending 31st March, 200___ of father/mother/guardian/husband of the student Shri/Smti/) __________________________________________ is Rs. ____________________________________ (Rupees ____________________________________________________________________________) Signature of the Issuing Authority Full Name _________________________________ Designation ________________________________ Seal ______________________________________ To be certified by the employer incase of Government employee and by M.P/M.L.A/D.C/S.D.O Civil incase of others. *** Certificates to be attached by the applicant:-- (i) Attested copies of Mark Sheets and Certificates of all the Examination passed. (ii) Scheduled Tribes/Scheduled Castes Certificate issued by competent authority. (iii) Age Certificate from Matric or equivalent Admit Card. (iv) Hostel Certificate (applicable for hosteller only). PART - B (To be filled in by the Head of the Institution where the applicant is studying. This application is to be forwarded after scrutiny for eligibility before the last date of submission). (i) Who statement made by the applicant in Part (A) are correct to the best of my knowledge. All the certificate has been checked. (ii) The applicant is studying in _________________________________________ course in the institution. The minimum qualification for admission in this course is _________________ _ (iii) Exact date on which the applicant joined the Course/Class this year and his/her Class roll no. (iv) Likely date month and year on which the examination in the present session will be over including Practical Examination.) ______________________________________________ (v) Name of the nearest Branch of State Bank of India through which the payment of the Scholarship is desired should be state here _______________________________________ (vi) The student is required to pay the following fees during 200__ which are not reimbursed by the State Government or from any other sources. (a) Admission/Enrolment fees Rs. __________________________ (b) Registration fees Rs. __________________________ (c) Tuition fees Rs. __________________________ (d) Games fees Rs. __________________________ (e) Union fees Rs. __________________________ (f) Library fees Rs. __________________________ (g) Magazine fees Rs. __________________________ (h) Science Lab fee for science(subject with practical) Rs. __________________________ (i) Medical examination fees charge by the _____ Rs. __________________________ (j) Examination fees: (i) Charged by Institution Rs. __________________________ (ii) Charged by the University Rs. __________________________ Total Fees payable during 200__ 200__ Rs. __________________________ I undertake that the Scholarship amount in respect of the applicant if and when placed at my disposal will be disbursed by me. In case the applicant leave the Institution or otherwise discontinue the studies or accept any other regular scholarship/stipend, the Scholarship will be refunded in the Government account. Remark by the Head of the Institution Recommended/Not Recommended Signature of the Head of the Institution with Seal No. ........... Place ........... Date ............ ____________________________________ Name in Block Letter OFFICE SEAL FOR USE IN THE OFFICE OF THE DIRECTOR OF HIGHER AND TECHNICAL EDUCATION MEGHALAYA : : : : SHILLONG In case the application is found to be incomplete, reason of objection:- 1. Total Amount of fee Rs. ____________________________ 2. Maintenance with effect from _________________________ to ______________________ Total of 1 and 2 Rs. _____________________________________________________________ Amount passed for payment Rs. ___________________________________________________ (Rupees ___________________________________________________________________ ) 0nly Checked by : _____________________________ Dealing Assistant Dy. Director of Higher and Technical Education, Meghalaya, Shillong
